NCC203642_NOI Signed Certification_20200824

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DENIER Stormwater Program (with $100 checklf paying.by check) at:
Division of Energy, Mineral S_ Land Resources Stormwater Program
512 N. Salisbury Street, 601 Floor (Office 640.K)
1612 hail Service Center
Raleigh, RiC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per h1C GeneralStotute 143-215.68 (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, repoi-t, Man, or other document filed or required to be maintair7ed
ur7der this Article or a rule implerneiltirlg this Article ... shall be quilt y of a Class 2 misdemeanor which may
include o fine not to.exceed ten thousand dollars ($10,000)
Under penalty of law, I cei-tify that (check ali boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satlsfying the
requirements of this permit, and for any civil or criminal penalties incurred due to vioiadons of this
Permit.
The infermztion submitted in this 1\101 is, to the best of my knowledge and belief, true, accurate, and
corep!z' to based on my inquiry of the person or persons who manage the system, crthose persons
directly responsible for gathering the information.
L I v,,IlI 2hide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
N If the approved Erosion and Sediment Control Plan is not compliant with Part II (Storniwater Pollution
Prevention Puny of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part li of the permit are met on the project at all times.
N' I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
ibis Pei v,riil constitute the permit requirern.ents for the discharges} and is enforceable in tine
same marines- as an individual permit.
Dame of Project: Mi,e MOlt'iDO'S aF 'I'-eyly-gh"-7 P,6wta.ho 1.a(i,Vf2C 7,6 9 T )
I_egally €iesponsHile Organizational Entity:
Legally Responsible Person: jritk l W0(jkq -
Title of Legally I rsponsible Person: i]G,l.r\+
':Signature: PA446.ZWA1J.t, J Date: 1" l -.2- 20
*Print Name end Title e1 Signed if Authorized
111dAo o0.1Gi{-)S)roo-1 Per)nl!ilee:
PhoneNomber:
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