NCC210676_NOI Signed Certification_20210203

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NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
i, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
rerol Statute 143-21S.68 (i), any person who knowingly makes any false statement, representation, or
n in any application, record, report, plan, or other document filed or required to be maintained under this
rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
thousand dollars ($10,000).
of law, I certify that (check all boxes to indicate your agreement):
i the person responsible for the construction activities of this project, for satisfying the requirements of this
mit, and for any civil or criminal penalties incurred due to violations of this permit.
information submitted in this NO[ is, to the best of my knowledge and belief, true, accurate, and complete
ed on my inquiry of the person or persons who manage the system, or those persons directly responsible for
hering the information.
ll abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
PI' n.
If :he approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of Part II of the
p�rmit are met on the project at all times.
1� I ereby request coverage under the NCGO10000 General Permit and understand that coverage under this
p rmit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
in ividual permit.
DSI Properties
Name of Project (must match Ala)
DSI Properties, LLC
Legally Responsible Organizational Entity (must match B1)
Timothy Sealey
Legally Responsible Person (must match B2 & 83)
member
Title Qf Le all Responsikr� P on (must match 83b)
2-2-2021
"Signature Date
timothy Sealey
*Print Name and Title of Signed if Authorized Individual Differs from Legally Responsible Person
910-635-7981
Phone Number
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as.a president secretary, treasurer, or vice president or a manager that is authorized in accordance with Port IV, Section B,
Item f6J of the NCG010000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the
NCG010000 permit.