NCC205318_NOI Signed Certification_20201201

NC\G01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload tothe electronic0CU.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
/ Division ofEnergy, Mineral /& Land Resources StormmmterProgram
51%N.Salisbury Street, 6mFloor (Office 64OK1
1612 Mail Service Center
Raleigh WC27699'1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION, HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143-215.6B(i), any person who knowingly makes uny/blsestatement,
or certification inany application, record, report, plan, orother documentfiled or required tobemaintained
under this Article mrarule implementing this Article ... shall be guilty ofoClass 2misdemeanor which may
include a fine not toexceed ten thousand dollars ($10,000).
Under penaltyof law, | certify that (check all boxes *mindicate your :
Ol/|amtheparsomresponsibkafnrthecunstruobnnactivitieamfthispnojeot for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
19 The information submitted in this NO| is, to the best ofmy knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
�
| will abide byall conditions nfthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
/
If the approved Erosion and Sediment Control Plan isnot compliant with Part U8tonmxxaterPollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions of
Part Uofthe permit are met onthe project otall times.
E2 | hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asonindividual permit.
Name ofProject: N\eA5\e\ )NJ- 1}0ICL
u
-Legally Responsible Organizational Entity: C_4� J (A0AQ14P_
Legally Responsible Person: E�\A\Aecc-
Title of Legally Responsible Person: Er\m!\,,er
*Print!\Iame�pcl tie of Sljq�d if Authorized
*IMPORTANTNOTE. This form must besigned bvo responsible corporate officer that owns oroperates the
construction activity, such mso president, secretary, treasurer, nrvice president, oromanager that is
authorized in accordance with Part IV, Section B, Item (6) of the 0CGOD0000permit.
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