NCC204682_NOI Signed Certification_20201021

NCGO1 Notice of Intent (N01) Certification Form
Directions;
Pi -in', this forril, roillplete, scan and upload to the electran 1100 .
Them mail the origind form to the NC DEMLR 5tormwater Frograrn (vrith $7_QU cl'ieck if paying by check) at:
DiOsiUll of Energy, 1v1ineral g: Land Resources Storlrn?,+atet, 1-rogram
512 I.. Salisbur-V Street, Vh Floar [01TE 64R)
1612 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 Ge?7eral Sfot'uie 143-215.68 (I any person ;vho knovdng1y n7akes any jLl1SE stQ4eniel-, , repi"esent0hiln,
or Certification 117 any 0ppliC0tior7, record, report, plan, or other docunienr filed or required to be rntinta?ned
under this Article or a rule hmpiemenf ino this Article ... SO be guilty, of a'Clpss 2 misderneonor which may
1?7C1de aPne not to erceed ter? ihm, sgnd dollars ($10,000,),
Under penaly of 1?th? Ce:'_l tit lc'i Oliecit all AXES to indicate yaw agreement):
I art} ia4 persc n responsible Di- -the construction oCTiV E% of till project, for Wisfy ng the
recuirements of tlAs Merritt, and for any civil or criminal penalties incurred d.re to vicia'.'ions of this
perilit.
"!' -(he ii?-Crnnation submitted in thk NCA Is to the be& of my kno,,vledge and beileff true, aCcurate; and
Complete b;ased cn my Quiry of ME person or pemons who manage a s stenj or those persons
directly responsible for gathering the infonnation.
3f 1 wK We by all conddons of the NC6010000 General Permit and the approved Erasion and
Sedirnent Control Plan.
NZ A
IT the api:.roveu Fi0s;'Dr, n Sedin-.Erri Control An IS not cNoNint witi":'r''a! H jioi'Cllamor WWI)
Prevention flail) of the NCG010000 General Permit, I will nonetheless ensure that ail conditions of
Part 11 of the perirdt are islet on the project at all times.
I i' emby request coverage under the NCG010000 General Permit and understand I.hat coverage unrder
this Pernni' will ccin5titu c the permll reclukeinlents for the dischaiT e(s) and is enforceable in the
Smile rnanne: as nn individual permit.
s0 -EB
1_egally Respniisible C)rg?nizationa! Entity:
-I_egalQ Responsibb Person: --qn n 1Ajx1kT"
Title of Legally R gmnsible Perso:t;
-SignaLr re: Da Le: —__ ------ — --
'Print Name and TIE w Spent =iAvMoGed
Plimie lquniber: �•
;if ,i" i i.i+C+u:+ic- i,:4 r :-„r it! S,_r i+ n it Nem 8y qf Me iPhht ,`r5liiau?h'11+'i+ .
For ...x = . - _ . _ _ = ..._."7_ .:�, see partA NtEEK0 . r-',