NCC203999_NOI Signed Certification_20200918

NCG01 Notice of Intent (NOI) Certification Forin
Direcl.ions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`F' Floor (Office 640K)
1617 Mail Service Center
Raleigh, NC 27699-1612
Per NC Genera! 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.
Cfi 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.
M I will abide by all conditions of the NC 601.0000 cieneral Permit and the approved Irosion and
J Sediment Control Plan.
iJ if the approved Erasion and Sediment Control Plan is not compliant with Part II (Storrwater Pollution
Prevention Plan) of the NCGOlCIO00 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
M✓ I hereby request coverage under the i�#C€-;O I.Otlrli) c_;eneial Permit and understand that rover•age 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: Ce,.(A-Aa •6wws5 UKQ lr&5u✓o v%Q
Cv. P1Jk4c i
Legally Responsible Organizational Entity_ Act�a U cul,rtrs 7 5 ur4.�nc` Cc,,�
Legally Responsible Person: L) ion y�j, /� )Coe
Title of Legally Responsible Person: l%\ LQ - P/-Q . r" .-v — ¢!'<xk1, t"0' ] SV✓ f�,y
*Signature:
Date: �—
*Print dame and Title of Signed ifA ithorized
Individual Differs from Permittee:
Phone Number: S 17 w 3 23 i 201 `7)_-0
* IMPORTANr 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 NCG0.10000 permit.