NCC204034_NOI Signed Certification_20200917

NCG01 Notice of Intent (N
I) Certification Fora
Directions:
Print this form, complete, scan and up
oad to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater F
rogram (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resc
urces Stormwater Program
512 N. Salisbury Street, 6tn FI
or (Office 640K)
1612 Mail Service
Center
Raleigh, NC 27699-1612
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 knowi
igly 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 ($10,000).
Under penalty of law, I certify that (check all boxes to indicate
your agreement):
I am the person responsible for the construction activities
of this project, for satisfying the
requirements of this permit, and for any civil or trim
nal penalties incurred due to violations of this
permit.
C The information submitted in this NOI is, to the best
of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons
who manage the system, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the NCG010000 Gene
al Permit and the approved Erosion and
Sediment Control Plan.
C If the approved Erosion and Sediment Control Plan is
not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit,
will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
1 hereby request coverage under the NCGO10000 General
Permit and understand that coverage under
this permit will constitute the permit requirements for
the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project:$;r
Legally Responsible Organizational Entity:
,..
Legally Responsible Person: C :_
Title of Legally Responsible Person:
*Signature: �" t._- �lAy
Date: ,/1 O-b^ C
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: C L%
�E
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
NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section
B, Item (6) of the NCGO10000 permit.