NCC210034_NOI Signed Certification_20210106

NCG41 Notice of Intent (NOI) Certification Form
Directions;
Print this Form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEML.R 5tormwater program (with $10D check rf paying by rheck) at.
Division of Energy, Mineral & land Resources 5tormwater Program
512 N. Salisbury Street, 6,^ 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 143-215.68 (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 (chetk all boxes to indicate your agreement)
!1[ 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.
i The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based an my inquiry of the person or persons who manage the system, or those persons directly responsible for
1 gathering the information.
will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Pion.
If the approved Erosion and Sediment Contra! Plan is not compliant with Part II (Starmwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part iI of the
permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match A1a)!
Jackson County Green Energy Park
Legally Responsible organizational Entity (must match 81):
Jackson County
Legally Responsible Person (must match 82 & B3):
Don Adams
Title of Legally Responsible Person (must match 93b)
County Mar
'Signature:
Date:
Prin} `Name and Title of Signed if Authorized Individual Differs from legally Responsible Person.
/fin• �nl�,r� ..ice' .31 .,. ��., _ �� Jr�A.yAr - - --
Phone !Number:
[phone]
IMPORTANT NOTE: This form must be signed by a responsible corpora to officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a monager that is authorized in accordance with Port IV, Section 8,
Item (6) of the NCG010000 permit. For more information an signatory requirements, see Part IV, Section 8, Item (6j of the
NCG010" permit.