NCC204647_NOI Signed Certification_20201016

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form; complete, scan and Upload to the e)ecti-onlc 1-%10!.
Then, mail the original fmm to die NC. DEMI_R StornlwMer Program (with $100 check if paying by check) at:
131411 ion of Energy, Mineral & Land Resources StOiwwaater i ! grain
512 N. Salisbury Street, 16*" Floor (Office 64,3K)
16a.2 Mail Service Centel -
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
PEr AIC Gen rai Sto'tute 1 ,3-21.5.Su (l), ony person who klaoU,),ngly makes any false sh;i ement, repr ecent0 on,
or Certification in Oily recor'o" report, Man, or other document fried or required to be lnaintained
under this Article or o rule i;npien,e.t?ting this Article ... shall be guilty of d Class 2 rnlsde nlearlor ttrhich may
include a flee not to e; ceed ten filo !sued dollars ($10,000).
Under penEhy Of I21'rl, i Ce`tifr' hat (check all PDXES to indicate YOW abr ernerd):
u I am the perSGn rcSIDOnsll:lle for the construction actiViSs of this pr O ECt, for satisfying the
reg0r mems of this iDerinit, and for any civil or criminal pencltles incurred due to violations of this
aemlit..
The info---natio'i submitted in this N01 is to he best of Iny lmoodedge and belief, trice, accurate, and
conlp!:;tE based cis my Illy:i q of file pewan or persons who nnanagE ilia syste;ll, or thuSE persons
c{irWN responsible for gathering the information.
f
19 1 thrill abide by aH conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Liar,.
Ito If ME aprwaved Er o.;,on and Sed;n-,enr Control Phn Is not compliant i+diet": Part II tSioi':_}ii+Jatcr Pollution
Prevention Dian) Of tl'1e NC6010000 General Permit, I vAll nos teal"reless enstire that all conditions of
Pali lI of the permit are net on th:. project at all tines.
LV I he.rEby request coverage udder the NCGO10000 General Permit and understand Lhat coverage tinder
this ernf` will C ns!itirte ;he permit requirernents for the dischai-Fe(s) and Is eilfc•rceable ill tihe
,;ime Mial'111CC as al iildib+d-UF11 permit.
Name of Project:—_U 1ap-�0" Maxi w '_�—
I_ega€ly ResponsiLde Organs; ational 1=nt Y:Air jr 14, C p
Legally Fvesponsible Person: }[ ox) W - ---��- - --
Title of Legally Responsible Perwi"4.
4
Da Le:
%'NhA Name and We iio Slued it Authorised
Phorie klun-fiber: J
uiliirltf,r.�Ci rlr rip'{'r.i+t;u:n;r rr i it r- )i i iw'. arrilr:,rr'+ c+, ii n! (t7[ Q] me [`vt i70.+r.Vi A IJrtlw.
For.. _op ,:..,-... _,. - _ `..:.._ ;fir see Par /K WON; Q sea: 74 AT G' =16 --.ii;