NCC204350_NOI Signed Certification_20201009

NCGO1 Notice of Intent (NOI). Certification Form
Directions:
Print this fbrrn,. wmplete, scan and upload to the electronic NOL,
Then, mail the original form to the NC DEMLR Stormwate.r Prograrn (with $100 check if paying 6y checic) at:
Uiaiision of:,Energy, 'Mineral & tand Res roes Stormwater program
512 N.Sa4tburV'Street, 611 Flaor (Off i�ce -640K)
1.612 Flail Service Center
Ra.leigh,,. N.0 2,Z699-16.1.Z
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REWEWED A)YD ACCEPTED AS COMPLETE
Per M 6t*erd ate 143-ZlS_68 91, aW peter wim knomn9iy awes ter -false stotemmt, representation,
or certifuation in any upoid'd7tion, recor4 report, Plan, or oilier docurnent filed or required to he mawtwned
under this Artkk- r- a ride in*enxwtWg t1iir,.Arbbfe.... sal, ,be grOftya-fs CAmu z t T&*kb may
include a me ,not to exceed ten thousand dollar's J$10,€ Wj-
Under enalty of law, I certify that (check all boxes to indicate your agreement):
i am the person resporzs-Ne for the constructia-lactwaWs of this Project, frrr satisfying the
requirements of this permit, and for any civil or criminal penalties incurred ague to violations of this
permlit
E°The information submitted in this Noi is, to the best of my knowledge and belief, true, accurate, and
compiete bassi on my is gidiry of the person or peas whD marrage the system, or those persons
directly responsible for gathering the information.
I vAd aside by all con ttioxns of the _ W - _ __ and the approved Erosion and
Sediment Control #Mars.
if the approved Erasion and Sediment Cantmi Plan is eat compliant vMh Fart It (Stormwater Pollution
Prevention Plan) of the NCGQIQQQQ Generai Permit, 1 will nonetheless erasure that all conditions of
Part It of the permit am met am t pm�w-t at aki des.
1 hereby request coverage under the NCGQ10000 Genera I Permit and understand that coverage winder
this :permdt an W omistiturc the permit regquireff mAs for the discharge(s) and is enforceable in the
same manner as an individual permit.
name of :Paco* ct
L a4kp' i st r4 gax ii �d l' iris rty ' lJrtlt f i t � �s
Legally Responsible Persan: _ LLB
T- fie of
.ible Person:
*-Signature., Date.: _ . --Z,3 1,;,o
Print ftame and Tide of �i$nedi rf Authodzed
Indic iduct Differs. froth P'ermitte .: �f� J00: 7-0 120-05,
* IMPORTANT NOTE. This fo m must be signed'by a responsible corporate officer that owns or operates the
constructforr acdvity, such as a presIdenty, secretary, trea.suret° or vice preesldent, or a rr anag.f�r thct.rs
authorized in accordance with Part W,, Section S, Item (61 of the NCG010000 permit,
for -more information on signatory re€iufremertt's, .see Part TV, Section B, Item (5) of the NCG010000 permit.