NCC205161_NOI Signed Certification_20201113

NG01 Notice of Intent (110I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEM LR Stormwater Program at:
Dieision of Energy: Minera I & La rid Resources StanTwhiater Program
512 N_ Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-161P
Per NC General Statute 143-215.6B (t), arry person who knowrr?giy mokes arrry false stowmen[, represerrtatt n,
or certification in any application, record, report, pion, or other dxwnent fled or required to be maintained
raker this Article or o rarie rrrrpierrkenvag this ArgioJe . _ . sholi be 0r ty of a Class 2 misdemeanor which many
indUde a frse not to exceed ter? th005asd dOikWS ($10,000)_
Under penalty of law, I certify that (check al I boxes to indicate your agreement):
O] I a m the perm responsible for the conmctbn activities of this project, for satisfying the
requirements of this permit, a rid for any evil or crimina I penalties incu rred due to violations of this
perrrrit
® The information submitted in this NOI is, to the best of my knowledge and belief truer accurate, and
complete based on my inquiry of the person or persons who manage the 5ystemr or those persons
directly responsible for gathering the information -
HI I wil I abide by a II conditions of the N CG010000 Genera I Permit and the approved Erosion and
Sediment Control Plan_
W If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO100Q0 Genera I Perm it, I will nonetheless ensure that all canclWoris of
Part I I of the permit are met on the project at all times_
M I hereby request cove rage under the MCGO10M General Permit and undersM rid that coverage Under
this permit wil I constitute the permit requirements for the discharge(s) and is enforceable in the
sa me manner as an individual permit
Name of Project: Dollar Genera I - Pelham Store #22537
Legally Responsible Organizational Entity:
* Legally Responsible Person_ Zach Cruml
Te rarno re Constructi o n
Title of Legally Responsible Person: Senior Vice President
Signature_
11 /9/20
* IMPO RMYT NOTE, • This form most be signed by a resaorrsibf& corporate ofj-rer that owns -or operates the
construction activity, such as o president, secretary, t rarer, or vkce president, or a manager dwt is
authorized in aceordaanee with Part iY 5ectron 8, ftem (5) of the NC6010000 permit[_
for more information on signatory requirements, see Port ;V, .Section 8, Jtem (6) of the NC6010000 permit_