NCC210524_NOI Signed Certification_20210128

NCGO1 Notice of intent (NOt) Certification Form
Directions:
Pant this form, complete, scan and upload to the electrnnk- Nf]I_
Then, mail the orkginaI form to the NC DE MLR 5tormwater Program (with $100 check it paying by check) at:
Division of Energy, Mineral & land Resources Starmwater Program
512 N_ Salisbury Street., 6o, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699.1612
DO NOT MAIL THIS FORM OR PAYMENT
LINTILYOU R APPLICATtbN HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC Gerterad Statute 143-215.68 (1), 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 rude implementing this Artkle ... shall he guilty of a CFass 2 misderneanor which may include a fine not to
exceed ten dtvasond daaa►s ($10,61W).
Linder penalty of law, I certify that (check all boxes to indkM* your agreement):
?� I am the person responsible for the construction achvrties of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
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.
I will absde by all conditions of the NCGQI¢M, fttryUal_permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (5tormwater 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.
jQ 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.
.?913 M IAA" ChOff eH AP•1D
Na me of Pirated (must match A 1 a)
_ bA AJ 1.WRTN1A) Sd)'J
Legally Responsible Organizational Entity (must match Eft)
j 4AI Il"f►l +VTlrrinr.<6W _
Legally Responsible Person (must match B2 & IR3)
E-Oi"►wae
Title of Legally Responsible Person (must match 83b) ►
1/
'Signature
'Print Name and Title of Signed if Authorized la&Wduol Differs from Legally Responsible Person
7,0 C/ - ST,F 49rG2--
Phone Number
' IMPORTANT MOTE This form must be sioned by a resporwl a ro►pnrate off3PPr that awns or operates the const►uctxm activity,
surer as a president secrewry, treasurer, or vice pnesmdent, or a manager that is outtioNrnd in onrordaner with Pratt IV, Simian 8,
Item (6) of the MCGO10000 permit For roars infwrnamo on s►gnatory requ►re►nent5, see Part IV, Section 8, Item (6) of the
NCGO10ow permR