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HomeMy WebLinkAboutNCC210836_NOI Signed Certification_20210212Directiorm, Print this form, complete, scan and upload tothe electronic NCU. Then, 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 51JN.Salisbury Street, GmFloor (Office 64OK) 1612 Mail Service Center Raleigh, N[27699-161Z DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE P�0[�n�l�o�����'G8/�m��mo whomo�� s��me� repres or certification in any application, record, report, plan, or other documentfiled or required tobemaintained under this Article ororule implementing this Article ... shall 6eguilty q/oClass 2misdemeanor which may include ofine not to exceed ten thousand dollars ($10,000). Under p, nalty oflaw, |certify that (check all boxes to indicate your agreement): Iannthe person responsible for the construction activities cfthis project, for satisfying the requirements of this permit, and for any civil or criminal penalties incurred due to violations of this pernn/t &k"' 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. z-s~~|will abide byall conditions ofthe and the approved Erosion and Sediment Control Plan. Ifthe approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution Prevention Plan) ofthe | will nonetheless ensure that all conditions of Part |(ofthe permit are met onthe project atall times. | hereby request coverage under the NCGQJ.00Q0 General Pemijtl and understand that coverage under this permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner asanindividual permit. � Name �Pm|e�/�� L � ����/l������ �—~^7 c~l �r/ o Legally Responsible organizational Entity: W 61�&jl4f -e, f Y JCLI") 6) r /31�1 fY) _X 1 (� 'IO��h Date: ^�`. u� �� ~c/ .~ ^PrintName �one6��u�z��dIndividual Differs from Permittee: & u u ��|� /, �� 17��r� Phone Number: | � / - �kin-v - ��-/ .�_/ *iMPORTANT NOTE: This form must be signed byoresponsible corporate officer that owns or operates the construotionoctivit)4 such as president, secretary, treasurer, or vice president, ormmanager that is authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCGO10000penn/t