NCC204775_NOI Signed Certification_20201023

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print ihi`; forrih; complete, scan and upload to the electronic. PJO!.
Then, nhaii the original form to the NC DEMLR Stormwa er %gram (1;'ith ` 100 check Cipoong by check) afi:
Division of Enet-gy, Mineral & Land Resoumes Stornhlhrater Pi Oporn
512 N. SaHhury Street, 6=F' Floor (Office 6/,0K)
1612 (trail Service Center
IWINgh, NC 2/6941612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per 10 General Statute 13-215.0 (Q any person who knowingly makes any false sto-Cement, reprecen [ot on,
or cop I man I on it) ol�y upprrlcotio,:, recorto; report, plan, or other dOcumienu f fed or ?rGUfrG'C7 to be 171oint 7hie
under this Article or a rule inlpremewing this ihtcle ... shall be guilty a1 a' Class 2 rniscerneonor ,,,,,hich may
include o fine not to exceed Ten fhousand dollars ($J0,000).
Under penaky of Ia 4 1 cE:'_ky that (check all boxes to indicate your ag eemel6'_):
u i am the persGn responsible for the consil uct€Gn aCT[VlileS of this project for SatiS 'dng the
requirements of this pert -nit, and for any civil or Cl`!S I penakies ilhruued due to vichtions of Ws
0annit.
The In1:o-nation subnAtted in this N01 Is, to the best of my kno.vledge ar6 hello?', ti-lUe, 2CCur'2te; and
comp!_,, based C.n n y inquiry of the person or persons 'J.'l1G nnanage thz- Systei'h. or t c'Se persons
directly responsible for gathering the information.
f ! wW We by all condihons of the NC6010000 General Permit and the approved Erosion and
Seeimas Control Plan.
t" TnE ap;=Ed C.I V K and SeditT,i-m Contl-ol Pin Is not compliant ii i Pare it 4JtQi'c'livvdici P011uilu11
Prevention Plan) of the NCGO10000 General Permit, ! will nonetheless ehsure that all conditions of
Part Il of the permit are met on tih . project at all times.
I hereby request coverage under the NCG010000 General Permit and understand dial coverage under
this penul will constitute the permit requirements for -the di dares ay and A EnImeWe in the
;a.me rnra ;net as an indivic;uai permit.
Nalh e-ofi project,Ind wff J, JotJ/,-J�#'�f
Legaly Res, ensilde Drganhational Entity: ' Cp�11 n�-✓� � % �[AT
-LegWy Reymnsible Person,_ no -- — -- --- ------ -- the of L cgAj Faslansihle Perso,h: - '�j{f"4- - --- - -- - ---��
"P hnt Name and WE E OY Gic 18d if','?u'MONed
Phone ivun3beu
110i''C11•...l.'', A._.2 n n ! p .._.-C'a s 1 ne d by a resp OnSib ce CO,j`._.. 11 i 0. _. C 0 :,; HMO [r
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