NCC205195_NOI Signed Certification_20201118

NCG41 Notice of Intent (N01) Certification Oorm
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR 5tormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources 5tormwater Progra
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 APPLICATI N HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute I43-2I5.68 (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 misden eonor which may
include a fine not to exceed ten thousand dollars f$10,000).
Lind r p alty of law, I certify that (check all boxes to indicate your agreement);
LV l am the person responsible for the construction activities of this project, for sat sfying the
requirements of this permit, and for any civil or criminal penalties incurred due o violations of this
permit.
The information submitted in this NOI is, to the best of my knowledge and belie , true, accurate, and
mplete based on my inquiry of the person or persons who manage the systerr, or those persons
irectly responsible for gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approve Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II ( tormwater Pollution
revention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at aft times.
I hereby request coverage under the NCG010000 General Permit and understan that coverage under
this permit will constitute the permit requirements for the discharge(s) and is a orceable in the
same manner as an individual permit.
Name of Project: - � ��� Wke4e N�
Legally Responsible Organizational Entity: MAA 1 C
Legally Responsible Person: , v► Otis tK
Title of Legally Responsible Person: �v
*Signature: Date:
*Print Name and Title o`f Signed„►fAuthorized
Individual Differs from Permittee:
Phone Number:
*IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manG ger that is
authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part iV, Section B. item (6) of the NCG010000 permit.