HomeMy WebLinkAboutNCC204622_NOI Signed Certification_20201014NCGO1 Notice of Intent (NOI) Certification Form
Directions:
PI'i11' tNs fornn cCrl1 Ye`% Scan and upload to tll2 electronic J' CX
Then, mail the original form to the IBC: DEIMLR S'torlllwa-ier Prograrn (v.Mh 5100 check if pgving by check) at:
Division of Energy, N'v neral & Land Resources Stornw.,later i-iograni
512 N. Sallsbury Street, 6`�' Floor (Office
161- % Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
r
Per NC Genera[ Stotute 1 3-21S.6u (i), ony person who ki)oviling'ly makes any f alse stotenierit, repre"entotion,
or certification i17 017j` Opi7i1Cat10l' , record, report, plan, Or other docun?eni filed or required to be nlalntainP.d
imder 'il?is Article or i? rule inipeoienfing this Article ... shall be guilty of a'Class ? misderneanor v,fhich moy
inchide a fine not t0 exceed ten trier?sued dollars ($10,000).
Under re;:ky Of AM l ce:tfy that Pheck all hoD:es to Indine your agl omen' ):
u I am the person rEsponsHble for the construction acWties. of this I Iokcl, i v sMN Vg the
reglllrenlenis of this pumit, and for any Wil or criminal penFities incurred 4r'`.Je to Joiatlons Of this
pennii.
f-Ile information suL'I1 Med in this N(N IS, to the best of my knDINIedge and belic-t tr.'e, accurate, and
comp l__E based oil my inquiry of the pemon or persons `JJilo manage the syst''nn or those- persons
directly responsible for gathering the idormation.
IS/ i wW We by aH conditions of the NCGO10000 General Permit and the approved. Erosion and
SedinllentC.ontiof Plan.
It" 1ti'ie api:,rWEd Ci't an and Sadi nam Control Pin is not C.i3mphant lh5h Pal II YtDrn1'trva r PoIlliiion
Prevention Plan) of the NC6010000General Permit. I will nonetheless ensure that all conditions of
Part II of the permit are met on th-a project at all times.
I ilercby request coverage under the NCGO10000 General Permit and understand N.hat coverage under
Ws penult 01 constitute the parnilt re-qUirEnients for the discharg e(I and A Enforceable in the
same mannci as an KdMdUal permit,
Name -of Project:
l7
AWRA u , Ph`1, 2C �Ci+lnl 2C
Legally Respcnsil,le C)ry?11haticnal Fntii:y:p"5"AkA__�
-Legally Responsible Person: ---�3n Yl aI.� q f" — ----------��-� � ��3
`I-itle of Legallyy Regmnsihle Kxon: I0' <Crx+' - -- l
*Signature_, l `
----�— --------------..-._ Dare: � -- 0 Q.----
*Prds Name and Ede o•: 51nen i ;3 MoQed
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