NCC205534_NOI Signed Certification_20201203

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
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 APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (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 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty 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 satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
The information submitted in this NOI is, to the best of my 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.
® I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
® I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit.
Name of Project: Golf Links System Strengthening
Legally Responsible Organizational Entity: Piedmont Natural Gas Company, Inc.
Legally Responsible Person: Khalid Boston
Title of Legally Responsible Person: Dis ibution Project Specialist
*Signature: Date: //-274--ZG7-0
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: 704-587-6941
* 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 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 NCG010000 permit.

Piedmont
Natural Gas
Memo to File:
To: North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources
Date: April 15, 2020
Subject: Delegation of Signature Responsibility for Water Permits; National Pollutant
Discharge Elimination System (NPDES), U.S. Army Corps of Engineers, and other
Federal, State, and/or Local Water- related Regulatory Programs
This correspondence authorizes General Managers, Project Managers, Project Directors, Distribution
Project Specialists, and Resource Center Managers to act on behalf of Piedmont Natural Gas with respect
to signature and decision responsibilities related to water regulatory programs. This signatory authority
should only be exercised after the project personnel have consulted with Environmental Services (Subject
Matter Experts and/or Field Personnel).
This delegation applies to signature authority associated with Federal, State, or Local program activities for
project -related water permit applications and certifications. This includes, but is not limited to, signatory
authority for Financial Responsibility/Ownership (FRO) forms associated with Erosion and Sediment Control
submittals.
This delegation does not grant signature authority below the General Manager (Gas Major Projects) or
Director (Gas Operations) positions for any non-compliance related documents such as correspondence
related to Notices of Violations (NOVs), Notices of Deficiencies (NODs), Notices of Intent to Enforce or
similar enforcement related documents.
Brian Weisker SVP & Chief Operations Officer Natural Gas
Type or Print Name l Title or Authority
L2!c, ac,
Signature Date
- - - - - �h--- - ---�-------------- r -------------------------------------------------
I, a�n L- W a , a Notary Public of the County of e�JIGI eV� v
State of North Carolina, hereby certify that 1(1 (M (- [JUX i'�;f^'VY , appeared personally
before me this day and being duly sworn acknowledge that the above form was executed by him.
Witness my hand and notarial seal, this day of Y I l , 2a
SHANNON L. WALL
Notary Public, North Carolina
Mecklenburg County
My Commission Expires
.tune 28.2022
Notan
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