NCC210438_NOI Signed Certification_20210126

N CGO1 N oti ce of I rite nt I NO I I Certification Fa rlrl
Direuions;
Print this form. Oom plete, scan and upload to the eJectrortic N01.
Then, rna-PI the original fern 140 the Nt DEMLR :5tormwatcr Program (With l check rf poying by Chock) at=
Division of ErKirgy, Mineral & Land FC0,s0ur es 15torrnvrater Program
512 N_ Salisbury Streel;, 6" r-Imr (of m 0K)
1612 Mail Service Center
Raleigh, NIC 27��-1i512
DO NOT MJAt TM FS FORM OR PAYMENT
U NTIL YOUR APPLICATION HAS R1EIF N EREVrEWEO AN D AOCEFTED AS COMPLETE
Per AfC Ge^LTyd Statate 14�3-235_m ri), Ony persm who know ingfy crakes &nYfia,e Start-n i ni4 repre5erpta[i0rr..0r
Cer0f�*Vr00 irr ar,y 43arrow, &,card, rePOM purr. dr 6ther document f fied or regwred to be rrrair,wrrred undee this
Arth�fe or & ruk irrpk-me Ring this Article _ . _ shall he:runty Pt a Class 2 mrsderrgnor %thich May rn.!;.'vde o fnE. rtot to
Exceed teen t houSaad dg01pr5 ($1Ct)-
U nd -r penalty of law, I certify tlpat (rh ds all boxes to i rtdicate your agreertrertt):
I Jleel am the pq� rson resPorrsible for tFw. rorr5tructiorl activide5 of th is prajert, for satistyi ng tlh(-. req u iremcrtits of th is
permit, and for -anyf citric or cri rrti real perkalties i ncu rred due to violatiorrs of thi5 perrn it_
Nile information submitted in this N 01 is, to the best of mar knowl-edge a n-d b-alief, true, accu raw, a rud complete
hayed on my irtqui ry of the Gerson or pe rsons who rrra wage the system«. Or Llhose persons -d irt!ctly re5poinsi file for
gatheri ng the Anformation_
1 I wi If abi-de 4 all cortditior* of the NCG0100W -3Fbrwral Pcrmf t an-d the approved Ere5ioa a rtd Sediment Contra I
Plan_
FiK If th-C apprawed Erosion and Sedrmerrt Contra! Plan i5 not c-orrtpl iant with Part I1(5101`mwater P0f1 ution
Plreventi Dn Plan M of the NCGG7 00(k) i3err.L%ral Pi-rmit� I wall rioriOtiheless ensure that a 11 v�r,ditions of Part JI of tk%
permit arp met on th-c project at al I times.
h-ereby req west coverage under the NCGQ I0W0 General P�, rnit grid under-5tand that corL-rage under this
permit wrl I canstit to the permit requi r-em-ents for the discha rge fs} ig rrd is enforce-ab!u �n the sam-e rrta nne.r a5 an
indivi-dual permit
Name of Project (must match Ala)
c
nsi ble Or rirzational Entity (mu-vt n7atch $1 )
tlyr Responsibk Person (nwur match �2.& 03)
I )
Title -Of L.e&alfy R,esponuihle Person (must match 63b)
"Sig #Uri Date
'Prirrt Name anid Title of 5rgned if Authorized JF)&vrduar pWf -rx f%rn tegaJPy -Respori5ihL- P'
Phone Number
HWOArMw . Wi f mn muxf be signed by d mpowrbte co pomtp ofirmr dF at ow ni W operates the roonstrucrom ardiuily,
wrh as 47 pt'5+ e"P serretffy, tMaRU'er, or wire praes;deh� or a manager that is OuMorrr,,d in aavfoamcr with Fart O V, 'gakn 8,
J (6) Of NFe NCGO20mo pffmrt For more infomMOGin on .QynCr1(3ry rWvkemen1 , 5eC Port IV, r'�ri 8, OtCM f6ji 40f th&
KC6010Ibl aAnart,