NCC204386_NOI Signed Certification_20201002

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DENril_P, Stormwater Program (u, Ah $100 check if pmying by check) at:
Division of Energy, Mineral & Land resources Stormwater Program
512 N. Salisbury Street, 61 Floor (Office 64.0K)
1612 Mail Service Center
Raleigh, NC 27699- Y-1 )
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
er NC General Statute 143-215.6E (i), ony person vvhc knowingly min kes any folse statement, representation,
or cert1dodon & orgy application, record, report, plop, or oti72r documer7i filed or reouii ed to be mointuir,ed
under this Article or a rule implementing this Article ... shod he guilty of o Class 2 misdemennor i,lhich n;oy
inciude e fine not to exceed ten thousand dollars ($10,000.).
Under penaky if 1,w, ! ceriffy that (check all boxes to indicate `y'o`!r agreeilleio):
I ai -i hi pewon responsible for the construct on activities of this project, for satisfying the
re,drements of this permit, and for any Ail or KnWal peneWes irci_irrecdl d',le to violations of this
jlcl-rnit.
The infornnation SUbmitted in this NO! is, to Be best of my kwujedge and belief, True, accurate, and
ccf;;pieie iLzseLd on my Inquiry of the person or persons whc MS=ge the SYMM, or those persons
directly responsible for gathering the informaton.
j 01 aide by A conditions or the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
II ile ai pi,cwed Erc'sion and Sedimcis Cori= Pin is not COili iiai1 1+vitil Part li (SlornlVvater Pollui:iol)
Pmvention Puri) of the NCG010000 General Permit, I uvill nonetheless ensure 'that all conditions of
Part Il of the permit are met on the project at al[ times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
-[his perirnl 1'•llll conStitlrte the permit r equiremEnt5 for the and is enforceable in the
some n•ianner as an 5XIdua] perm4t.
Nan-ie of Project_:
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Legally R.,-sponsible Organizational Entity. � V� `C
!-.egally 3?esponsibie Person; I d(7,1')
the of Legally Responsible'' --Perrson: LYA?.X)t T
"Sisnaturc: Vl�-fie'. Date: BI1a LvZO
Fits Name and We of Signed 6f AuMorked
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