NCC203976_NOI Signed Certification_20200914

irectiorts:
'Print'this form, cornjakete, scan aind uoload to the e4eetronie Alttit.
There, melf the original, form totheNC DEM'LR Stormwater Program (with $100'check if paying by check) at:
@ivisiorn of'E,nergy, ineral & Land Resources Stormwaterr Program
512 N.'Sali-sbury Street, 6" Floor (Office 640K)
1612 Mil Service Center
Raleigh, NC 27699-1`6112
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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 due to violations of this
permit.
The information submitted in this NOI 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 system, or those persons
directly responsible for gathering the information.
RF-'r t will abide by all conditions of the . a __ _ _ . _ _ . and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO .0000 Generai Perrr.f7 I will nonetheless ensure that all conditions of
Part it of the permit are met on the project at all times.
1 hereby request coverage under the _ �. _ ._ and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project:
4
Legally Responsible Person: 1-11 / 1Upe'1.<lS
Title of Legally Resp#ftle Pe
*signature: //A k, ' /'N-I— l Date: exi g
*Print Name and Title of Signedij Abthorizea'
IndiuiduotDiffers from,-Permittee:
Phone Number: 1p�%5—
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Sections &; Item (6),of the NCG010000 permit.