NCC205653_NOI Signed Certification_20201210

NCGO1 Notice of Intent (NO[) Certification Form
Directions:
Print this fornn, complete, scan and upload to the eICcsonic NfO!.
Then, mail the original -form to the Ili: DE11 LR Stoi wwa-•ier Program (vdith $100 ched iJ poong by check) at:
DiviNon of Energy, I'vlinerai & Land RESOurCE 5ioi'nwater Program
512 I'L Salisbury Sheet, Ph Floor (ONVe 64R)
1612 Mad Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
I
Pe!" NC General Stufute 143-21.5.6E (i), ony person who knov<<ingly makes any folsc st-u�Emtenr, 1'ej71'e5�17iQ'if017,
or certijicotion in any 01.)p`ic0tlon, record, 1-cpofi, plop, or other docw en'� fi,'ed or required to be 177a117tained
under this A.riicle or o rule inpienieritil7g this Article ... shall be guilty of o'Class 7 m1demeanor v�Akh may
include Ci jine not to Pxceed ten thoosund dollars ($10,000).
Under penalty of law, Ce:. i'' hiat Nheck all boxy to MdWe yow apmemers):
L' I am the I)ersGn responsible for the construction activities of this IDroject, for Satisfying ",he
rC-gUirernenis of this perml, and for any Civil or cdmin l I?enalties i1curred d''I.."e to violations of th0s
5(1 T The in�ornnatior, submitted in this i401 Is, to the best of In i kno,vlecige andd, belie tnue, accut'aate, and
compHE bwe,d cn my inquiry of the person or persms 'arho n,; irfase iNi syst'�I-n: or ihosi_ persons
clrectly responsible for gathering the information. 4
1 wN Me by all conditions of the NCGO10000 General Permit and tl:e approved. Erosion and
Sediment Control Plan.
—'1 4 Lnr approved Er000n and SeUIn ent contiol Pin is not coo I.Jhani vvii : igl L ii (Sto r!nvvate PolkILIUII
Prevention Pion) of the NC6010000 General Permit, I will nonetheless ensure that all conditions of
Pali it of the pem)it are met on t17:: liroject at all times,
I r I hercby request coverage under the NC6010000 General Permit and understand i,hat coverage under
this permit will constitute the permit requiremens for the discharge(s) and is Enforceable in the
same rnaruix as an indMdLiai permit.
Namaof Project: Ofthm' Yl V�f d su�br� yh n a,�el cols 10 4, 119 r 30� �� I , + 4 k7
Legally Responsible Organizational Fntii:y: ��r� CdY1���,��� . i '�1�. ° 52 � ISS 15'1 1558
I_egaHy Responsible I`'crson;— )f`l&n
Title of Lepalht Resi,ansihle Person:
Mgnatwo.— Clacr�
'' Akt Flame and ";. iVe o:.-
M6111irful?l L ii' 1 s .'-rorr; i tee.
I'noilr, Number: L� 41 m �1�'-N� i b�lr7 IJ
t t.
ih!ii�( l:1, .i�l�.s" .._, .... '+'ia to G• .ed by a f'esj1G'iriwe colyCneve c;j'..... 10' w7z i . .ir::=i':._._ H.;e
rll of 1.0dog r rrW AN A! ?rAii)r? & Am f61 {))rtfii2 =01300 11: lW.