NCC205541_NOI Signed Certification_20201202

NCGO1 Notice of Intent (N01) Certification Form
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 paying bvcheck) at:
Division ofEnergy, Mineral & Land Resources StnrmmmterProgram
S1ZN.Salisbury Street, 6mFloor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MANLTH|S FORKI OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (J), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article. . . shall beguilty ufoClass 2misdemeanor which may
include ofinenot toexceed ten thousand dollars ($20,000.
Under
penalty oflaw, | certify that (check all boxes toindicat
e youragreemen1):
|nmthe person responsible for the construction activities ufthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit
The information submitted inthis NO|is, tothe best ofmyknowledge and belief, true accurate and
complete based unmyinquiry ofthe peoonorpersons vvhomanage the oystem or
directly responsible for gathering the information.
'
/wiUabidebyaUcondidVnsofthn
, and the approved Erosion and
Sediment Control Plan. �---------
�
y� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit/will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
| hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit x------'--------~~
requrement�forthedischar8e(s)andixenforceab|einthe
same manner asanindividual permit,
Name of Project: L
[l -
Legally Responsible Organizational Entity:
Legally Responsible Person: J
-.Title of Legally Responsible Person:
ajnitl�eof Signed �iffAuthorized
Individual Differs from Permittee:
Phone Number: -I q6��
*IMPORTANTNOTE, 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 manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit,
For
see Part IV, Section fLItem /6/cƒthe yV[G010000permit,