NCC204274_NOI Signed Certification_20200929

NCG01 Notice of intent (NOi) Certification Form
Directions:
Print this fDrrn, CompletE, scan and upload to the WWI NO!.
hen, mail the original form to the NC. DEN,11_11 StonnhwMer R agmi-n (,,With $100 check if laying bycheck) at
Division of Energ;`,i, Mineral & Land Resources Si:orniwater Program
512 N. Salisbury Street, 6"' Floor (Office 640K)
1612 Mail Service Center
Raleigh, 1`IC 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.G8 (iQ ony person Who knowingly makes any false statement, repreSentoti0ll,
or certfjicotion in any air .kation" record, t-c-port, plan, GI other cocurnent fled or required to be nnaintained
[alder this Article or a rule inlpiementing this Article ... shall be guilty 0)` a Class 2 rrliscerineanor th'llich tllay
include o fine not to eyceed ieli inoosund dollars (; 10,000j.
Ulhder penEIty Of 12VJ, 1 ce:'ti',,, that (check all boxes to indicate you agream I'.{.:):
v�1�% I am the PErso n responsible for the construction actlVities of thi5 project, for saiisf'y'ing ine
requTements of this penal, and for any civil or ri-irnln2l penalties incurred due to viola ions of this
'oenn-�il.,
`�' fhe ii';'unratlon submiked In this NCN 11 to the best of my knowledge and hOiEf; trte, cCCurate, 2nd
complate based cin nny iinqu ry ofthe person or persons, who manage the system or those persan5
d;rectly responsible for gathering the information.
ORf i v>tirili abide by all con Mons of the NCG010000 General Permit and the approved Erosion and
Sedirnent Control Plan,
J II tilt appro'Jed lius;on acid Sauimmu Comol Pin Is not i.{)IYWilaril Willi Pat li ti.ri"iDi"m%'dicr i'&ll on
Prevention Tian) of the NC6010000 General Permit, I will nonetheless ensure that all conditions of
Pan II of the permnli are nlet on the project at all times.
I hasby request coverage under the NC6010000 General Permit and understand that coverage udder
this pern-,iZ vv-Al cc)nstitute the pennA requil-ements for" the diSCi MeW and Is EnAme:aMe in the
same rnannu as an individual permit.
Name.ot Froject:_A!21 rl'Yl
Legally Responsible C)rg,anhational Entity: C'pnS' 11. i nC
Legally Respons±ble Person, _ }ifo,t'`°y W- lke — ------------- --
Title of Legally Responsible Person: 'L{,X�-� —
t Q Imo/
oifcbol-irpi, i!l o{ 1.0 Own r nQ r K ii.'.SAW it Am Ooi clihe =i:',6010rJrlInk
For mono hntaycltr _ . - _ .. _...c11`c rce Par lid <<'.ato f_=, ,-c:,: -= AT ".r"I"