HomeMy WebLinkAboutNCC205406_NOI Signed Certification_20201124NCG01 Notice of Intent (NOI) Certification Form
Directions:
Prlrit this i0rt-n., complete, stall and upload to the e-lecCron;c. 1,401.
i hell, mail the original forll' to the NIIC: DEIALR Stormwater Prograrn (with S100 cl-;eci, i}`rya}�?ne Icy chnck) at,
Division o'i Energy, 1\4Iineral & Land Resources Stornivfater Proeranl
512 i.l}. Salisbury Street, 6'i' Floor (Office 6_,10K)
161-, Mail Service Center
Raleigh, 1\C 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
I
Per/VC Genet olS otutL 143-215.0'E jij, orly person who knot iingly r1iakes any folse stafemen , representation,
01"CEl"tif'CQ'ti017 in U17j d1�3Ui?CLltrC+J7, record, rcport, pion, or other documer1- fiie0' or requi1'ed to be 11 ah7toined
under this Article or a Alit: hmpleJ7 eating this Article ... shall be guilty G1` a class 2 misCeolea of Iv/1 ich mQY
i0CIUde O fi17e ?70t t0 `,iceed ten fhousai7d Dollars ($10,000).
Under penEity of 12la+, ; ce: ffl), hai (check all boxes to Indicate your agreement):
u I am flit 11cr5G11 i'c5i"�Olislillc i�Jr ill2 CO{lsil'GCtiGli aCilVlileS Oi' iiils I�{"ojcCi, Gi' S2ilSs)fitig'illE
requirements of this permit, and for any civil or cf imin21 penaitles incurre6 due to violations of this
Gerilill..
�11 The ;n-:'crriiation SUbmitted in this 1,C1 Is, to the best of rn1! aPd belief, tl'L.e, accurate, and
con'ip,late base-d 7 v' ;y i ") c` he person persons mild ai e il'i� S steli7: Or ih3se_ persons
• irll i t li !.J 1 1 YL ISt�IICI`! 2"SO i
directly responsible for gathering the information.
1 1vr11 abide by a!i conditions of the NCG010000 General Permit and the aPproved Frosion and
Sed'rnlent Control Plan,
u O:0SC01tr01 �iQ1 15 i0f CGI'lillil J": �al'110ldcI p' Ei " pollution
S''e
Prevention Pull) of the NCG010000 General Permit I will none-theless ensure that all conditions of
Part 11 of the permit are met on th . project at all times.
I herebv request coverage under the NCG010000 General Permit and understand #.hat coverage under"
this err"slit- Lvill cunwiltute the peri-nit requirerneiltS T01'the disChGr C-(5) olld IS ilfC:iCe311Ie ill file
war"sic rnarinei as an individuai perl-nit,
R#anle-of Froject: :fA-D &
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Legally Responsible DripnlZationai Entity; ` ►.�� _� D�r1�i��1'�� ' � mac- ` _
L.egaPy Responsible Person: ------------
Title of Legally Responsible Person: ' ax±
*Sigriatur'=_—a -------Date:
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"Print 1\;ame and TilIe co. 4i-_!'Ieb 1),;]vfho li7ed
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Phonei\Iuniber:
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