NCC203811_NOI Signed Certification_20201013

NCGO3 Notice of Intent (N01) Certification Form
Print th is form, com pl ete, sca n a n d u p l oa d to the electro nic N 01.
Then, mail the origins{ form to the NC bEMLR 5tormwater Program (with $100 check rf paying by check) at:
NvIsion of Energy, Mineral & Laird Resources Storm Ater Program
12 N, Salisbury Street, '� Floor (Off iCe 40K)
1612 Mail Service Center
Raleigh, NC 27699-1612
a0 NET MAIL. THIS FORM DR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per N C General Statute 143- 1 5.6B (j), a ny person who kno wingly makes any false stotement, represen to tio n,
or certification in any application, record, report, plan, or other loco ent fled or required to be maintained
under this Article or a rule implementing this Article t . f shall be guilty of o Class 2 misdemeanor which may
include o fine not to exceed tern thousand dollars ($10,0 ).
Under ena lty 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.
0"'o The information submitted In this N01 is, to the hest 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 gatherrng the information.
L�r I will abide by all conditions of the NCGO10000 General Permit and the approved Erasion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Nan is not com ia nt with Part 11 �tormwate r Pollution
Prevention Plan) of the NCG010000 Generai Permit I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the.NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
sarne manner as an individual permit.
Name of Project:
ti 0 73
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6-vt o wow f WZ.
Legally Responsible
Organizational
Entity:
C
Legally
Responsible Person:
,- f
rcol
True of
Legally ors fble
Person:
U.,AV
—*Signature:
*Print Nam
Individual 01
and Tine of Signed if Authorized
s from Perin itte.
Date: Y12
Phone Number: 70 — `-7 7 -117
* IMPIMPO R TA NT NOTE: This form must be signed by a responsible corporate officer that auras or operates the
construction aativit , such as a president, secretary,, tre-usurer, or vice pres1dent, or a manager that is
as h red n accordance , Section B, Ito (6) of the NCG010000 permit.
Far mare information on signatory requirements, see Part / V, Section 8, 1te m (6) of the NCGO10 0 pear it.