NCC205031_NOI Signed Certification_20201105

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, COMMeN, SCan and UlJload. to the elC-0-0niC.: MICA.
Then, mail the original font to the NC DEMLR Stonawater Prograrn (with $100 ched<i1 pnonc by check) at:
EAVIAn of Energy, h1ineral & Land Resoul'ces Siornwvater i=rograill
512 [,L Salisbury Street, 61 Floor (Cflice 6 M
1612 Mail Service Center
Raleigh, NIC 27699-16 12
y
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per PVC General.Stafute 143-21 .Gu (i), ony person who kr?DiVingiy 117akes i`ny folse stuzemiern', repres-entotion,
or cert/j`icotion in 011), L pl1 licotion, record, report, Plan, or Other documenicfiled or required to be n3aintained
under this Ai -ticle or a rule implementing this/article , .. shell be guilty of a Class 2 inisce rneonor 1,vhich naay
include a fine not to eYceed fen thousand dollars (.510,000),
Under pe.":aly of I?t4r ! ce: _fly hat (chOc'.0 all boxes to is dWate yow agre'enimu"):
II aril the perscn responsible for the construction actiXes of As project, TO,;, satisfying the
rR-,Uirements of this penult and for any civil or crimin?l penalties incurred dlue to violations of this
�� I''✓clilzll..
The h formation subn1lti'ed in this j\CI Is, to the bes of my l(novidedge and beilem fl-Ue, aCcUrate; and
I- lowed cif Il y lilgil j �f file PEMOn or pers0 S 1d m to �
CC1n1;� �.� it ivhG alai?arc il'ie s'y.'S," !; Dr thuSi:. eel-.,oi?S
directly responsiNe for gathering the information,
i ta.il) abide Ky ali conditions of the NCG010000 General Permit and th-e approved Frosion and
Sediment Cuntrol Plan.
- _
Ifthe approved [i'O.`>i0i�i ,�Ciu 5CU1113enL CVnti"ol flail is not L.L''i1"'rl3ilc:rit vitili: 'r'al-'i II i.ri'iOrililrtia'ici' PollLi-doll
Prevention Plan) of the NC6010000General Permit, I will nonetheless ensure that ad conditions of
Part Il of the permit are met on the project at all times.
i I i lerEby reques coverage under the NCGO10000 General Permit and understand Lhat coverage under
this permit will congitute the IJEri A reC{Url-enients for Ke dis.Chzi-pe(s) and Is enforceable in the
sa,1?e niarinci aS all iildi',,i&lal permit.
Nw-ne-of Prof (:i,J _ae Ems_'r- ` vWO'n i Ph 0,itV n 3L-7-14 9
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LegallyResponsible Organizational Entity: -��4 C pAsty11`nY,�
Legally R.esponADle Person: - lC`1a1�,P- ��e .�_�_------.— ------ ---- --
TMe of Qgally Resporisihle: Person: ' Cr + _
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*Aint Name and We oy SyneO i, AL' holed
l? divio,ui jf L,:!?& 1 S jro( ri
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