NCC205767_NOI Signed Certification_20201230

NCG01 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
512N. Salisbury Street, 6mFloor (Office 64DK)
161IMail Service Center
Raleigh, NC27699'161Z
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Per NC General Statute 143-215.6B (I), any person who knowingly makes anyfolse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include oftnenot tnexceed ten thousand dollars ($I0,00O).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
X 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
X 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.
X1 | will abide byall conditions ofthe NCGO10000 Gnneral 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) ofthe | will nonetheless ensure that all conditions of
Part ||afthe permit are met onthe project atall times.
* | hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
Legally Responsible Organizational Entity: NW Lake Wylie, 0 LC
ResponsibleLegally Steven Hinshaw
IndividualTitle of Legally Responsible Person: ember
*Signature: Date:
*Print Name ardTiffe of S-igned' if Authorized
Differs from Perm
Phone Number: [phone]
*/MP0RTPA;VTl`40TF- Thisƒhnnmustbesigned byoresponsibiecorporate cffker.theittnwnsoroperates' the
const,uction activity, such as a president', secretary, treasurer, or vice president, or a manoger that -is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, Section B, Item(6) of the NCGD0000permit.