NCC204708_NOI Signed Certification_20201019

NCGO1 Notice of Intent (NOI) Certification dorm
Directions:
Print this form, complete, scan and upload to the electronic NO .
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 chec if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Progr
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICAJION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false stato ment, representation,
or certification in any application, record, report, plan, or other document filed or requi ed to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misd meanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® I am the person responsible for the construction activities of this project, for atisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
® The information submitted in this NOI is, to the best of my knowledge and be ief, true, accurate, and
complete based on my inquiry of the person or persons who manage the syst m, or those persons
directly responsible for gathering the information.
® 1 will abide by all conditions of the NCG010000 General Permit and the appro ed Erosion and
Sediment Control Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part I (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit:, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
® I hereby request coverage under the NCGO10000 General Permit and underst nd that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: Pleasant Garden Storage - Phase 5
Leeallv Responsible Oreanizational Entitv: RP Clark GrouR k06
Responsible Person: Randal If3_ Clark
Title of
*Signature: ��-�li'�, Date: � 10/15/2020
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: [phone] u
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that o * ns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a m nager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.