NCC203411_NOI Signed Certification_20200825

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, c011113lete, scar} anO upload to the electronic 1\101,
Then, mail the orlginal form to the NC l-)EML111 Stormwater Program (with $100 check if paying by check) at:
Division of Fnergy, 1lriineral P; rand. Resources Stork- nwater Program
512 I\1. Salislaury Street, 611, Floor (Office 640K)
1612 Mail Service Center
Raleigh, N.0 27609-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per IVC General Statute 143-21.5.6B (i), ony person who knowiajgly makesany folse stotemer7t, represet7totio7,
or certification in anV application, record, report, plan, or- other docurneni filed or required to be maintained
under this Article or a rule irnp/l1177entir7g this Article .. , shall he guilty of a Class 2 n7i5den7ear7or which may
include a fir7e not to exceed ten thousand dollars ($10,000).
Under Pena Ityoft lava, I certify that (check all boxes to indicate. yout- agreement):
15�!I am the person responsible for the construction acVvities of this Project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
The information submitted in this. N01 is, to the Lest of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons vvho manage the sys em, or those 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.
if the approved Erosion and Sediment Control Plan is r7.nt col-jpliant witli Part 11 (Stornl%vater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all tines.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements fol- the discharges) and is enforceable in the
same manner as an individual permit.
IVante of Project: i r !e J a4 GeUh a4o t
Legally Responsible Organizational Entity: H LH �E}it��itJ;
]regally Responsible Person: "Brior) lea altlr eu
Title of Legally Responsible Person: p` A+
"`Siknature:
*Frint Name and Title of Signers if Authorized
h7di.viduol Differs from Perini tee;
Phone NUIII beI': 110 - (4 66_LtM, _
Date:
* 110PORY'ANT NIME, This form 177usi he Sigr-ed by responsible. corporate officer that owns or oPerai-es the
coras.truC.tion ac tfvity, such as a prrsicer) i, secretary% treasorer, c)r vice presiaeni.; or a 171a17r;ger th0t is
ouihorized in accordance 1'.'I:17 cart Al section 8, Item (6) Qf the ArCGO-10000 Pernlit.
For rOcTe infDrn7 'i icn on sigr7arory rt golren7enis, sc- Pert 11! 5ectiorr 3, Itel-17 (6) of the AICCO 0000 perr77it.