NCC203956_NOI Signed Certification_20200911

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print This forrn, complete, scan and upload W the ebUrril#1C 10M.
Then mail the original iwm to Me NC DEI'\9I_li Stor swMer Prograrn (with $100 cheek if po);Jnq by check) at:
Diddon of Energy, Wneral &; Land Resources Storn'nriater Program
512 N. SaliAury%Street, 6-r' Floor (D ficc 6-,.,OK)
1612 Klaii Service Center
Raleigh, NC 2764E-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per,'VC General Statute 143-215.6B (i), ony person who knowingly makes any false stoter77ent, representotion,
01' Certification in ony app),'ication, record, report, plan, orother docun-!ent filed or!-ecuired 10 be i-nai17taineQ
under th s article or o rule in7p emenfing this Article, .. si7cll be gUiliy of a Class 7 n7isC;ernea17or ivhich moy
include a f;17e not to eyceer7 ien ihoosund dollars (. 10,000).
Under renEAV of [E!w, ! ce;' l,f ::tat (check 211 boxes to Indicate your aomern& :)-
L Iarn tw person r6sponslrulefor the construction activliie'sof AN hryeci, rsatisfying the
regOmments of Ws perniilt, and for any civil or criminal penalties incurred due to viol2tions of this
�,
pern':ii..
!Y lie W? orrwaUor submitted in this 1\101 Is, to the best of my !<n-.,, `Iedge and I e at tn!% accurate, and
cornpl .E based c n my Inquig of the persmi or puscans o, manage lie system or those persons
directly responsib!e for gathering the information.
IL? I v,11i abbe by A conditions of the NCG010000 General Permit and tl-e approved Erosion and
Sediment Control I'ian.
u If the approved E o:>i n and SedKeni Control Plan is not carry s w w4h Part it tStumvaWr Pollution
Prevention Plan} of the NCG010000 General Permit, I vvill nonetiyeless ensure that all conditions of
Part NI of the pem-,it are met, on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage urider
this pennit will constitute the permit requ€r McMS for Me disc1,Ei-ge(s) and is eniforceable in the
same 1'narinei as an iindiVidLlal permit.
Name of Project: C�L02 OL --. .. - - ------
Legally Res,:en.sible Cogankatlonal Entity: H Cormcu;,4vrr,�:, ,o L?s
-Legaly Responsible F'cisr�n:--- jf"IAt"y flL1—,-------------__—�_
Title of Eegdy Rwsp,,nsihle Person:�-
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