NCC204032_NOI Signed Certification_20200922

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 Resounces3tonnvvater Program
SI2N.Salisbury Street, GmFloor (Office 640K)
1G12Mail Service Center
Raleigh, N[27699'1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEA
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143-21I6B (i),any person who knowingly makes onyfalse statement, representation,
orcer/if7ozbon/nany application, record, report, plan, orother docunventfiledo/required 2ubemaintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofnenot toexceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
1 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.
Z The information submitted in this NO] 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.
| will abide bvall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
co If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
| 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.
—Legally
—Legally Responsible Organizational Entity: (�.AQ_TaMET (fcw-t,o&j,T-r 6oLLzIG-C
b|
Title of Legally Responsible Person: VicZ Pee-Zy0cwT-,
*Print Name and Me of Signed if Authorized
Individual Differs from Penndtee:
*/MPOR7ANJTNO77. This form must besigned bvo responsible corporate officer that owns oroperates the
construction activity, such osopresident, secretary, treasurer, u/vice president,oromanager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.