HomeMy WebLinkAboutNCC204876_NOI Signed Certification_20201029NCG01 Notice of intent (NOI) Certification Form
Directions:
Print, this forrrl, completer scan and upload to the electronic. =-
Then, mail the orlginal fo m to the NC. DE111I-R St %water NvW-arn (xv"ith $1C0 chteck if ogying by check) at:
I)ivis on of Energy, Mineral & Land Resources 5torrnwater Program
512 N. Salisbury Street, 6,h 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
F
Per idC Generol Statute 143-215,6B (i), Grnypeison who kr DW,'0gJy niakes anyfolsc statel e;-)i, rc"pfesentotion,
or cel-tification in any up!);ication, rCco?'a`, !-c-pol-, f71011, Ol- other Glocutrie 1t filed tar?-equired to be maintained
under this Articile of- a mile in)lofe mi en Ong thk AN@ ... Shall be guilty Of a'Class 2 misoemteanor-vilhich moy
inchide o fine not to ezueed ien tiiousond dollars ($10,000),
Under pe:-.Ehy of 121Y, ce, 1-1y :hat Oheck. all box- to .ndlcate your agr een'4F1 ):
I am the person resporiSti lefor the constri Aon acTlWes of fills project, w- SdiiS j ng he
re,drernents of tNs penrlt, and for any All or crimin2l penF.lties incu reel due to viubdons of As
p e l-il- k.
The rt1'ormaUon suhmYtted in this NCI Is, to the best of my knmviedge ai,d belfet t-ue, accurate, and
corn lak band on my 1iNuiq of the person or persons 'dv'hG liianage 111= S"stel1l: or thoscPersons
directly responsible for gathering the information.
Pqr i wdl We by Ai wndibons of the NC6010000 General; Permit and the aal?;-caved Erosion and
Sed'srnent Control I —,!an.
'p� - c"" " "r - Control Pin is not con --,.Bari vjili`! Part Ii �5i0(iflifvaic#" Pollution
II it ill Ci IG'S+CI.! ErKan J!�Jri 21iU JCUII fiLIIL
Prevention AQ of the NCG010000 General Permit, I will none-theless ensure that all conditions of
Part it of the pem-+it are met can the project at all times.
I IIumby request cmerage under the NCGO10000 General Permit and understand i.hat coverage under
this ei-i-(,1 Vviil constitute the permit requirements for the disci ai—, e(sj and Is enforceable in the
satme rnannei os all int]MdUal permit.
Name -of Project, '-rvie &xv-s 1' ai,6ngd , ,S P-cb ) - Y, e Po-v Thyw J-
Legall�f Rrspal,sil}le Orgarli;aticn<I Entity:
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Legally Responsible F"erson: }C'ILcg---------
t"iile of Legally Rzsporisihle Person, �- ,
ualLe_ 1 `2 3W0
"AAA Name and ode cy s f—led !1;5L'[r70'led
J!7cowchho Mils Sol p;?(f'r W ee:
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i��i1�%I•:.,.tif:4'Y `'. ..,._; .. itosin d by n respoluibhoLo;1.+o1ke111:_e _..... ej vyervU5 the
rt; i) Cr:,rt :.r,::r ", ;., ,: ire rv. -S1 i trim 13, ifen-, (o)aj' ih,;,;x,CL7t,'_{iliri,'ti