NCC210303_NOI Signed Certification_20210120

Print this form, �complete, scan and upload tothe electronic N[V.
Then, mail the original form to the NCDEM0StormwaterProgram (with $100check -� Paying ' ' ' ���at:
Division ofEnergy, Mineral 8iLand Resources StonnmmterProgram
512N.Salisbury Street, 5`^Floor (Office 64OK\
1G1JMail Service Center
Raleigh, NC27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS SEE A-'""
Per WCGeneral Statute 143-215.6B(J), any person who knowingly makes mnyfabstatement, nrepresentation, or r
oer�/�n�on/nany 1��remor�repor�plan, or other | tfi&edorrr4u�edtobe^~^'~~^'`°°'=='��Ar�c/eororu�/np�nen�n�this�r�c6y'..shm0beouJ�vgfo{Joss2msoememnor which mayinclude ofinenot tV exceed ten thousand dollars ($10,000).
Under penaltyoflaw, / certifythat (check all boxes toindicate your agreennent):
r� /anncneuersonrespunsib|efortheuznstTucdonacbvbiesofthisproject,forsatisfyingvtherequinennentoofth/s
ermi� d for any civil or criminal penalties incurred due to violations of this pe |t-
cz /Me|ntonmationsubnnitted/n1hisNO(is,tothebestofmnyknowvedoeandbe|iettrue,acourate,andconnplete
based onmyinquiry mfthe person orpersons who manage the system, orthosepersonsdipectiyrespomsib1efnr
gathering the information.
�2 |will abide byall conditions ofthe INCG010000 Genera I Permit and the approved Erosion and Sediment Control
D|an. ------'
[L�^|f the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the /�^'�.'�/-'` `�/��`�_'�.�`,/will nonetheless ensure that all conditions nfPart Unfthe
permit are met onthe proJectatall times.
~� /hereby request coverage under the NCGO10000 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 Dermit.
Name of Project (must match Ala)
i�
Legally Responsible Organizational Entity (must match B1)
Legally Responsible Person (must match B2 & 83)
(must match B3b)
�
*Print Name and Title ofSigned
Phone Number
Legally Responsible Person
0MPORTANTMOTE. 7his/onnmust be5ionedbyoresponsible corporate offimrthat owns oroperates the construction activity,
such asopresident, secretary, treasurer, or vice president, momanager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO1000 permit. For more information on signatory requirements, see Part IV, Section 4Item (6) of the
ACBO10000permit.