NCC210657_NOI Signed Certification_20210203

2/1/2021 2021-02-01 - Updated N01 - Elliott Road Ext.jpeg
NCGO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic Nol.
Then, mail the original form to the INC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 60� Floor (Office 640K)
1617 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 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certification ir, any application, record, report; plan, or other documentfile-d or required to be mair:tained 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 (check all boxes to Indicate your agreement(:
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
The information submivtod in this N01 Is, to Tire tress ui my Xhuwletli;r and belief, true, & .LUfake, and tgnlpleie
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
if the approved Erosion and Sediment Control Plan Is not compliant with Part 11 (5tormwater Pollution
Prevention Planl of the Nr�(,o i opN-, rpneral Permit, i will nonetheless ensure that aii conditions or Part It of the
permit are met on the prolect at all times,
I hereby request coverage under the NC6010000 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.
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Name of Project (must match Ala)
TO n G'� a✓i4n ( m
Legally Responsible Organizational Entity (must match 81)
Legally Responsible Person (must match 82 & 83)
Title of Legally Responsible Person (must match 83b)
r,
*5i Lure Date ,
*Print Name and Title of Signe if Aut orized Individual Differs from Legally Responsible Person
Phone Number
IMPORTANTNOTF: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as o president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part )V, Section 8, Item (6) of the
NC6010000 permit_
https:llmail.google.comimailfulOi?tab=rm&ogbl#inbox?projector=l III