NCC205058_NOI Signed Certification_20201106

NLC301 Notice of Intent (NOI) Certification
Form
Directions:
Print this form, complete, scan and upload to the electronic NC
I.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check
if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h 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 143-215.6E (i), 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 ($10,000).
Under salty of law, 1 certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for
atisfying the
requirements of this permit, and for any civil or criminal penalties incurred due
to violations of this
—/permit.
L� 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 syst
m, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approx
ed Erosion and
ediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part
I (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit. I will nonetheless ensure
that all conditions of
, "'art II of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understiind
that coverage under
this permit will constitute the permit requirements for the discharge(s) and is
enforceable in the
same manner as an individual permit,
Name of Project: W�t� 1t�1 601'�,s Fl vCJ ecov'or
Legally Responsible Organizational Entity:
Legally Responsible Person: K ,e i lv A'ic'
Title of Legally Respons' le Person: r " tf— 0- '
*Signature:c��AXfd.,.Date:
20
*Print Name and Titleg Signed if Authorized
Individual Differs from Permittee:G
Phone Number: Z5 2, — 2 -t
�, `'i i� � ZZ
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that ot4ns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the I
CGO10000 permit.