NCC204818_NOI Signed Certification_20201027

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO).
Then, mail the original form to the NC DEMLR Stormwater Program (with 5100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143 225.68 (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, report plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($14 000).
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 satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of thcs
permit.
{ 1 The information submitted in this NO[ is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NC(3010000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the NCG01QQ 0 General Permit and understand that coverage under
this permit will constitute the permit requirements for the dischargels) and is enforceable in the
same manner as an individual permit.
Name of Project: Rusty OHGW Replacement Sternmons 230kV
Lqally Responsible Orgi nczational Entity: Duke Energy Carolinas, LLC —
Legally Responsible Person: Randy Veltrr — -- `-----------
Title of Lqally ResponsiPerson: Manager, Pefyndb g ._
•signature. ___ Date:
*Print Name Ad Vile of Signed i Authorized
--individual Ri ers Perrmttee_ ___....__ .
Phone Number: 104-362-.2741
r WPORTANT NOTLI_ This form must be signed by a responsible corporate officer that owns or 0;wrwes the
construction activity, such as a president, secretory, treasurer, or vice president. or a manager that is
authorized in accordance with Part 1V, Section R, item 16) of the NCGt3J0001 permit
Fix more information on svnatory requirementx, see Aart IV, woon B, from (bj of the N(601 00V prrrrr,t