NCC205201_NOI Signed Certification_20201113

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic 1'401.
When, mail the original form to the IUC DEN-11-1i Stormwater Program (with $100 check !j` lJaying by check) at:
Division of Energy, Mineral II: Land Resources Stornivoater Program
512 N. Salisbury Street, 6.h Floor (Office 6_110K)
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 143-215.6B (i), ony person Who knowingly makes any false staremen ,' representation,
or certification in any application, record,1-c-port, /An, or other document filed or required to be maintained
under this Article or a rule inmplementhlg this Article ... shall be guilty of Q'Closs 2 n7isdenvanor which moy
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of lave, 1 certify that (check all boxes to indicate your anreenlem):
L I pen the persGll I'asponsible for the construction activities of this project, for satisfydng the
requirements of this permit, and for any civil or criminal pent Dies incurred, true to viola+ions of this
Fern "it..
d I -he information submitied in this N01 is, to the lest of my knmNledge aM belief, true, accurate, and
con'I,llete based cn my inquiry of the person or persons who n-tanaage th4 syster i, or those persons
directly responsible for gathering the information.
f
I %kill abide Icy aii conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
L� y 17 tile-_ approved Eiosior, and Seuirrient Control Plan is not cornpliani with P"ol"i 11 yS IYI) +vatcl- Pollution
Prevention Plan) of the NCGO10000 General Permit, I 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 NCG010000 General Permit and understand I.hat coverage under
this Permit will Constitute file permit requirements for the discharges) and is enforccable in the
same manner as an individual permit.
Name -of P roj ec .-Ilz &
Legally Responsible Organizational Entity: � j'�O�`n� yq7 i::bl qweAei tq
Legally Responsible Person: Ii'1bt, walkq " ---- --- _--
Title of Legally Responsible Persoq: 'Aar .
"Signature-:
I'Print Narne and Thle oa' Sid;leci if;sLIi`.horized
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