NCC210089_NOI Signed Certification_20210205

NCGC1 Notice of Intent (N41) Certification Form
Directions:
Print This Torn"i; connpl t% scan and Upload to the elC-Manlc. NO!.
Then, mail the original form to the NC DEI' LR Stor mwMei Progi'arn (wAh SWO check if paying by check) at:
I kidsion of Energy, Mineral So Land Resoui'ces Siorrnwaier iogi-ann
512 N. SalisburV Street, 5`�' Floor (Office 6='01(}
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
Per W General Statute 143-215.09 (iJ, ony person who knowingly makes Grly false sta�'en"re1); represen tati0n,
or Certi7MCKD!7 W Ony CppliCGtia!?, record, report, plan, brother document filed or!Tquired to be moNtOned
under this Article or o rule inipleniewing this Article ... shall be guilty of a Class .? !r,icr,'cr„earrar ,,rhicr7 moy
include up'ne not to teYceed fen thousand dollars (510,0001i.
L)nC;eY penalty of I?w, I CC;"''':iy :'.`Icl Nheck all boxes '[C WNW }GLlY ab eI is
u I am the person rEsporjsib7 for the construction actiVides of This lwoj&ct, for satisfpirig the
rant{irernents of, this permit, and for any civil oi- criminal pen_TES i? cuued due to V! hNons of this
�? l Ile inforniatior submMed in AN t\101 Is, to the Hest of my I<nWedge ar d. beief, tr .e, 2ccurate, and
corm i "e based Gil nny in;gquiry Cfthe person or persons who nn.ana ge thE s stEm or those persons
directly responsibb for gathering the information. ?'
1 wK We Ly all cor,6itions or the NCG010000 General Permit and the apprmved Erosion and
SeArinof Control #Tarr.
II BE opiii"G'dcCa Civ:ai:ii': and Jcurlvcl]L Col1tS"OI 1=laii IS i1G'l ca31n'-il.-i,icilll with t'al"i II 45'iGi'i"litwaic!" PvIiL{`ilCn
Prevention Plan) of the NC6010000 General Permit I will nonetheless ensure that all conditions of
Part II of the pen -nit are met on the project at all times.
I inercl]y request coverage under the KG010000 General Permit and understand chat coverage under
this pernil will consT'ime the permit requirements for the dischaij c-(si and IS enforceable rceable in the
Say E imarl4lei as an individual permit.
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Legally Responsible C07anlzationai Fntity: H C!!r"I,�x eyi if�_
Legaily R.esponsilJle Person:____ nn&n Walk eT
T UN of Legally 0sponsihle Person: `fy"lt *Sigrlatur`e_ �_ — —__ _..�--- uatE lr_2 f �. �1w0A)_ __
*AKA Name and Me o'; Si neo 0 r)L'Thonved
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Phone Number: cfi �} a ��
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