NCC204027_NOI Signed Certification_20200917

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
PI'int this form.. cornplete, scan and unload to the ele=oriic NO!.
Then, mad the original form to the NC. DE11•'iLR Stot awater Prograrn (v,,ith $10o choci: if ooying by check) at:
Division of Enc-rgy, Mineral &, Land Resources Stor i)water P ograrn
512 N. Salisbury Stc-eet, 6=1i Floor (Cfice 64",10K)
7.612 Trail Service Center
Raleigh, 1`C 27699-1.61.2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
i ,
Per r�1C Gener"c! StatL�tr 1-,,�-�J,5.GB (i), anyperson vJ17a knol:,/117gi} 177L7iCE5 G1ry fQ,!
S,= Stui'er77E';7i; f"cf7!`e..E17iQ'i1011,
Qr certificotion in 017y aj..)Plicairor7, r-ecord, report, 1.�1Q!7, or other docu17-,eili filed or r-equi!'Cd to be 1 ointained
u17dEr this Article or a rule inipiementing this Arade ...shrill be gudy, of ci Goss 2 mrse,'eroeunor t<,,hich moy
include o fine not to Exceed ten i"!iousul-id do 1pf5 ($10,000),
Undee/r�pe::Eky, of he, l ce! fy that kheck ali boxes to MdWe your agmelllE!t':�:
L I ani tile pErson aspOnMINE for the construction actidVes of this pi-oject, for satisfying Mile
regLftements Won tfds permit, and for any Wil or Wind pEnc.ltiES incurred due to violations of this
pel!i"iII
The 1do's'mat;or subn1iaed in this NO! K to the Bast of my k! mviedge and belief, true, a cmrate, and
compive based 1 y the person or pemons v..,ho IllaiiagE th; s` ste! is or thOSE persons
Vit 1 1� inquiry l%� 1
directly responsible for gathering the information.
1 wW abide by ad conr,Mons of the NC6010000 General Permit and the approved Erosion and
Sediment Control Pal;.
' If ti'ie apprOvEd [i'i)5iM a0d Sadi!venz Control Pin Is not coiE'ii:riish lidi h Pak i1 (S"iurWlA%aicr 'rPNIUMn
Mention flan; of the NCG010000 General Permit I will nonetheless ensure that all conditions of
Pail 11 of ne per —dt are met on the project at all times.
l houblr requesi coverage under the NCG010000 General Permit and understand l hat coverage under
hage(. b
illia p�EI'il".it b';riil C;;nsi!tUtu tll2 IJerillii I'eC�u!i`el"iicnts for tll�E diaC�ic.i�.UlS) 3!lu Is EiiTC,l-CE2iJiC- in die
vane illallr)U aS a!i irldiVidUal permit.
l�alll2-ot Frcject: _�Li}--
Legady Responsible OrRani: ational Entity H � F`t LAl'��S�Ct�C,7 cif � -�� Ru —y' Wc,LU,
I..egally Responsible Person:
Title of Legally Responsible Person:
Da!ve:
'Print Name and We ca hyner_i 1JAvmowed
Phone NunilDref: rI " 1-1 1 (a- Ll NA,
.... '`r"`_. . ?: _ s" ie.1 by a !- spoil ible" col po c.�_ g nv i °i�_ _,,,
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c','O);nr ,•rQ0 AW:iE(fr(',ir r?,, itr'r+7 �l�tojrtlk� iW60.1i t%i.'v ui or}:.
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