NCC203581_NOI Signed Certification_20200818

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan find rjjpiosd to tho. electronic N01.
Then, mail the original form to t.l1e NC OF1\AILR Stormvvater Progra III (with $100.cIieck if paying by check) at:
Division of Energy, Mineral & Land Resources Stor'nlwater Pro.granl
512 N. Salisbury Street, 6t" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27099-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per IVC General Statute 143-215.GB (i), any person who knowingly makes cfr7y false statement, representation,
or certification in any application, record, report, plan, or other document filed or required tobe t77aintolnecl
onder-.this Article or a rule implementing this Article ... sl7all be guilty of a Class 2 misdemeanor which n7ay
hiclude a fine not to exceed tern thousand dollor's ($10,000).
Under penalty of law, I certify that (Check all boxes to indicate your agreement):
N( I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred clue to violations of this
permiT..
NThe information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the l3erson or persons Who Manage the system, or those persons
directly responsible for gathering the information.
S
I vvik abide by all conditions of the NCG010000 General Permit and the approved Fros.ion and
Sediment Control Plan.
if the approved Erosion and Sediment Control Plan is not compliant v%Qh Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I wiil nonetheless ensure that all conditions of
W Part 11 of the permit are met on the project at all times.
�f I hereby request coverage tinder the NCG010000 General Permit and understand that coverage under
this permit will constitute the pen'nit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Proiect;
i3 g y € i J i_egallY Res onsif3le Or anizational Fntit �; H�ir�.��uc�r�,
Legally Responsible Person: l ria'n wcc'e' "'
Title of I_eRally Resl3onsibie Person:
Q
YSignaCUre:1</1,Lh, Gate:
"Print N.arne and Ttle of Signed if Authorized
liidividuol Differs fi-m-n Pernli tee:
Pholie 1\1111Tbe.E 1 0-Yg(j- . 00, — -
7. c1,rr,rW +) 2
llir7P01k;1; h1T N10 E, phis form mosi be Signed by acnrl3ortrte officer That ovvns or- operates the
cDri` b[ )cticr7 such 0S 6! presider? ., 5ecr"etur')i treuu urer; or vice president; .or a 17mogge.r that is
authorized in gccor'dunce v rth Part Ill Section B, Item (5) qf the INrCC-:rr11�006 permit
For r7;cre on signatory regr?irer:7er'rts, see Port All 5eCtior7 B. 11eEno (6) of tiro N G01100 0 permit.