HomeMy WebLinkAboutNCC205755_NOI Signed Certification_20201214NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this. form complete, scan and upload. to the electron;C. 1"101.
Then, mail the origirtal fW-n-: o the NC D17I'01I_R Stornl%gamer Prograrn (with $1-00 cihecl< r'j`paying by chuck) at!
Dkdsiori of Energy, KIineral g: Lana Resources Storniwater Program
5121 N. Salisbury Street, 6-" Floor (041fice 64'01
1612 mail Service Center
Raleigh, KIC 2 j6g9-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
r
Pei' NC General StotLlin 143-215. 6-0 j il, anyperson who knowingly Ill okes (ari y f ois2 5 uiEr?i21 rr t, f"Efil e5Ef7 i Q�id!!�
or certificotion in any oppl !catio;7, record, report, pica, orother document filed or ?-ecuired to be n7ointalned
under this Article oi- e rule inip;emef7fino this Article ... shell be guilty of a'Closs 2 nlisderoeonor i,vhich cloy
OClilde O fl!7e not tp n, CeeJ fell th01j5ryl7d dollars ($10,00Qk
under penalty of 12;4r, ! ce:.tl;' that (chec€( all boxes to indicate your agreement):
u i am i ;c €1ci-scn rc-sponslble i,Gr the cons'iructi0n activi-des of tilis pro' i, iCr SailSi;'il"cij ilh2
requirements or This pert -nit, and for any civil or crlmincl !penalties inclined due 1-o viclations of this
penr,li..
The suh-mitced in this 1\10€ is, to the best of my kno,;-vledge algid helict; trr �, accurate; and
comp,! ',E €1G52d G11 i1 Y i01y,UI ry :;fih2 i721'5G11 01' 1]ci50i1[ :4!l1G liicilu4c'i11; SwSt'211i, Cr t11oSe pel"s01h5
directly responsible for gathering the information.
1 i4.i1i abide aii conollions or the NCG010000 General Permit and the a opioved Frosion and
/' .SedirnenLCoiWof Piak.
If tll-ie appN o'ded F-io5ioci &rd Scuii7ienl Control Plan Is IIOt 4i 1`i' L-i€Inlil W:10: Pal-T !i t }iCrt1it/taici" PoilLdI011
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure -that all conditions of
Part 11 of the purnlit are islet on th . project at all times.
IN/ I hereby request coverage under the NCG010000 General Permit and uriderstand that coverage udder
his Pern-,I Vvid constitute the permit requirements foi- the dlschai-Re(s) and is cnifc--ceal)le in the
sa.--n n-iannei as an individual permit,
Nar,1e-of Project:���'Z fit— -
Legally Responsible Cjrnani, ationt I Entity: H t �An us �r , #' v �cLLL-
-Legally Responsible Persr)n:-
l-itle of Legally R.-asponsible Perso,i:
signature: iaa i, c: I 8 ZO 2-
"-Print Name and Fille_ o: �ioried lj /�vtho!''%ed
ir!'6'iIritlo(?I Lrii f5 1'r7'Ii !'i?°:ti=e;
Phone NTtjmber�
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