HomeMy WebLinkAboutNCC210325_NOI Signed Certification_20210120NCGO1 Notice of Intent (NG1) Certification Form
Directions:
Print this 10rl-A, COnlplete, scan and upload. to the eJectron;r NO!.
Then, rnail the original forrr, to the NC: DEI'V'ILR Stormwater Prograrn (vAt-h $100 check if paying by check) at:
Division o"i Frierg'}i, kilineral & Land Resources Stornllr'dater Frogrann
51! K'. Sallsbui-y1 Street, 6`" Flo or (C% iicE 6-,C)Kj
!_612 Nllai[ Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per 1\1C General Stotute 143-215.0iu (i), 011y person who knowingly makes arty false sto-LeMIEli , represel7iQ[l01?,
or ceriljlLOtiol-, in any Op;]katloli, reco1-d' l-C-p01-L, p1011, 01' other docuj-,?ell file' or recoired to be 171aintoined
under this Article or v rule il)]plewe1'ifing this Article ... shall be guilty o1` o' Closs 2 n7iscerneonor t",4lich may
include a file not to e, Ceed t ell thousand dollars (- 10,0001l.
Under pe;,Gity of hat (check 2I1 boxes to indicate your abreen Lnt):
I am i;g- persGn resporisiblE Tot" the construction activities of this pro)coC, TGr Sai.iSf ifng'iile
reQ.Uirengents of This permit, andfor any civil or crirnincl Penalties incurred due to viol4 ions of this
i�erll,it.
'"�' The i!lrCrll'.atiMi SLIhill ftted in this i\i01 is, to the hest of my ICI Ct"'i?Cg' a"dl heIlEt, i' L-e, 2CCL:rate, and
CC3n'IN; c II Ed. -.1 ill ' Inquiry OTthe }Jerson or persons who n-lainage ihE 5'ySi'a "n,- Or thuSE persons
directly responsib'ie for gathering the information.
I vdili abide Ly ak conditions of the NCGO10000 General Permit and .Ile a;Jproved Erosion and
—� Sediment Control Rah.
If ti-iC a1)PI.0VE%i ci osi0!_ aInd Sculli,211L CVlli- roI Pian is Il0'i Corr'P1iani- With Pal'[ li j'S-L'oi-rnvva"L'er Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure shad: all conditions of
Bari li GT the pern-+it are met on th-a project at all tinges.
I lierEby request coverage under the NCG010000 General Permit and uinaei-stand Lhat coverage under
this NEI"iifii', VJil1 C0'tlsiituii file permit requirements for "the discharge(s) and Is enforcea[Dle in it"te
s_me rnariner as ail iildiVidUal permit.
Nallle of Project: 0 R-0-s--
Legally Responsible org?nizafional Entity:
Legally Responsible Iterslgll:�-
Title of Legally Rasponsihle Perso,i:—
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Phoine cT 0 Y 00,
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