NCC204256_NOI Signed Certification_20200929

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Prin", this form, comMse, stall and upload to the electronic N10!.
Then, mail the original forth; to the N( DEIVIL11, Stonlivtraier Pragmrn (with $100 ched,Vpuying by check) at:
DMsiori of Energy, I`viineral & Land. Resources SiOi'irwater Program
512 I:. Salisbury Street, 6'-" Floor (Office 64,0K)
1612 Mail Service Center
Raleigh, IBC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per,'VC General Statute 143-21 ,63 ail, any person who knowingly makes any false Sta�elliet",% 1'ePresentotion,
or certfkation 117 any CIpplicatio'i, record, report, plan, or other docun-fend filed or ? equireQ to Ike rnaintabie4
under this Article or a rule iniplementing this Article ...shall be audo of a' Class 2 inisderneonor vi!hich moy
include C fine not to exceed tell thousand dollars §10,000).
Under penEky of 12ly, ! ce:"tifjl ghat lcheck aH Loxes to indicate your agreeITler::):
I am the person responsible T71- the canstrikCUon actitrltles of hits project, iol- Satis'1 41ig idle
requirements of this permit, and for any ci H or criminal penalr4es interred due to violations of this
'oen ii%.
I Ile in-ormadon stibrnhted in this NCH i , to the best of my knowledge and heliet tl'L q accurate, and
comp! -LE baSea Cn nny inquiry of the person of pusms who nnailace the systC-111; or those persons
directly, responsi h for gathering the informadon.
r I wK We by Ai conditions of the NCG010000 General Permit and t,e app over Erosion and
SeoirnW Control Ilan,
I the a1]PMVEd [i"os on and S&dI riani Control 3Phn is not cowoliant vilili'i Part 11 SSior!'nkwaier Pollution
Prevention Plan) of the KGO10000 General Permit, I wRl nonetheless ensure that all conditions o;
Part II of the pern-rit are nhet on theproject at all times.
'L' I herEby request coverage under the NC6010000 General Peanit and understand that coverage under
this peri1`;i' vvill cCiihstitute the penal requirements for Mc discharge(s) and is Enforceable in the
same n"ianmei as an individual permit.
Nanle"afi Project: "CY12 /V�p,1' oj� a+ �Qx'IggHM pi� 2 J_?TI'� a_.Ir�(� —�Co 7/�, 7l 7
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Legally Responsible Coganhational Entity: ` ►�-KWIT C p S' G� Vic- ° 7/-J/
Legally;! Responsible Person: _ }[` ox) LAJAJ�(, "' —---'--------------...
Tine of Legally R'asponsihle Perso:l: {pr�". --
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*Signature:V4�,A,, L,a'e: LF[�� —
*41nt Name and l:t:ie oy S jned !fWoNee
i,+'!C2!IritTi!(1�Lr:;rf 1= ir)r}i. ,=1":r.,btee: j
Phone i trinber: �l (7--
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