NCC203600_NOI Signed Certification_20200820

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this farm, complete, scan and upload to the electronic NOL
Then, mail the original form to the. W DEMI-11 Stormwater Program (with $7.00 check if poying by check) at:
Division .of Energy, Mineral & Land Resources Stormwater Prog� nl
51l N. Salisbury Street, 6"' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1512
DO NOT MAIL THIS FORM OR PAYMENT UNTIL. YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.5B (i), 017y per-sora w17o I<rlo6n�lr7gly ri�alres crny false statemeat, representatior7,
or certification in 017y application, record, report, pic7n, or other- docuinenf filed or required to be moinathied
under this Article or a role implementing this Article ... shall Ue guilty of o Class 2 misdemeanor which moy
include a fine not to exceed ter? thoosond dollars ($1.0,000).
Under penalty of lava, I certify that (check all boxes to indicate your agreel-nent):
1 l am the person responsible for the construction activities of this project, i'or satisfying'Che
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
hermit.
jThe information s.uhmitted in this N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the sys-em orthose persons
directly responsible for gathering the information.
I will abide by all conditions. of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
l/ If the approved Erasion and Sediment Contml Plan is not cornpliant wiih Part Il (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit 1 will nonetheless ensure that all conditions of
Rart II of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this pel-mhc Will constitute the permit requirements for Lhe discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: YPY N nV J'e h' an One, Phw e rwa-AoH 38 & &8
Legally Responsible Organizational Entity: H Co� { , 1 ,&-
den
Legally Responsible Permi: Fi(kn Wker
Title of Legally Responsible Person; R-�,M+
�Signat.ure; , Date: f� V
'Print Name and Title of Signed if Authorized
lndividuol Dior,-r`s froli7 perliiittee;
Phone Nurrlber: 110 —1-48(j"146(yq,
IC1IPOI-?ANT (OYE-'; -his fora, muse be51gned by a responsible corporate office( that ovins or operr,ir
construction G'cVvity, sock OS o president, serretc,rj; treasurer, or vice presidel" t, or 0 1-nm7r gcr thr-t is
at M01-ized in C Ccr'dar7Ce t,'ith i'artw, Section P, Jtcm (6) of the 1l1CG010000peo-oiL
/ ('i f y 1
For more ir.)`arr'r7r..tio,1 or', srgnarory r�_c,tairel?�e17i_sSEE Port l4, ectlon ! , lt�n� C r tl7e <rc.G[7+CrC,00 �er'mlrt,