NCC204891_NOI Signed Certification_20201103

NCG01 Notice of latent {NOES Certification Form
Directions:
Print this form, complete, scan anti upload to the electronic NO1.
Then, mail the original form to the NC DE MLR Stormwater Program (with 100 check 1f paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512, N. Salisbury Street, 6,h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAI L TH IS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTER AS COMPLETE
Per NC General Statute 143-215,68 (1), ony person who knowingly makes airy false staternerrt, 4represemtation,
or rerttf cation in any opplicotioA, record, report, plan, or other document filed or required to he maiAtoined
under this Article or a rule implementing this Article ... shaii be guilty of a Cross 2 misdemeanor which may
include a fine not to exceed tern thousand dofiars ($10,000).
Under halty of law, I certify that (check all boxes to indicate your agreement);
71 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 this
permit.
The information submitted in this NO is, to the best of my knowledge and belief, true, accurate, ; rnd
compiete based on trey inquiry of the person of persons who manage the system, or those persons
directly responsible for gathering the information_
C�1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan,
'0/ If the approved Erasion and Sod! rnent Control Plan is not corn pIiant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit. l 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 NCG410000 General Permit and u nderstaA that coverage udder
this permit will conWtute the permit requirements for the dischargeJs) and is enforceable In the
same manner as an individual permit.
Name of Projectlr l
Responsible Organizational Entity, f r
Legally Responsible Person x I
Title of Legally ResponslbJe Person:
Date; l -1 ; -
*Print Name and Title of Signed if Authorized
individual D ffers roar permittee:
Phone Number
* I PORTANT NOTE. This forma must be signed by a responsible corporate officer that owns ar operates the
construction activity, such as a president, secretory, treasurer, or vice president, or a manager that is
outhorired in accordance with Part IV, Section 8, iterrr 161 of the NCGO10000permit.
i=or more information an signatory requirements, see Part IV, Section 8, item (6) of the NC 010000permit.