NCC205034_NOI Signed Certification_20201113

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NCG01 Notice of Intent (NOI) Certification
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATI
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false
or certification in any application, record, report, plan, or other document filed or i
under this Article or a rule implementing this Article ... shall be guilty of a Class 2
include a fine not to exceed ten thousand dollars ($10,000).
Under p alty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for sz
requirements of this permit, and for any civil or criminal penalties incurred due
ermit.
The information submitted in this NOI is, to the best of my knowledge and beli
complete based on my inquiry of the person or persons who manage the syste
erectly responsible for gathering the information.
:/Zed
Iabide by all conditions of the NCG010000 General Permit and the approv
iment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part I
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ntion Plan) of the NCGO10000 General Permit, I will nonetheless ensure
lofthe permit are met on the project at all times.
by request coverage under the NCG010000 General Permit and underst;
this permit will constitute the permit requirements for the discharge(s) and is
same manner as an individual permit.
Name of Project:
Legally Responsible Organizational Entit
I Aaally Responsible Person: 'Davi
Title of LegA"esponsible Person: N ;
*
*Print Name a
individual Dij
i� tS Ids '..�ha5c
of Signj�$if Authorized
n Permittee:
Ji'.
Date
by check) at:
HAS BEEN
-nt, representation,
to be maintained
,anor which may
:fsfying the
to violations of this
true, accurate, and
or those persons
Erosion and
(Stormwater Pollution
iat all conditions of
nd that coverage under
enforceable in the
A
Phone Number: 25 l 64— 1 1 —75
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that oivns 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 B, item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, item (6) of the NCGO10000 permit.