NCC210367_NOI Signed Certification_20210219

NCG01 Notice of intent (N01) Certification Form
Directions;
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($lo ooQ).
Under onsi enalty of law, i certify that (check all boxes to indicate your agreement):
/I am the person responsible ble 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.
LI✓ The information submitted in this NOi is, to the best of my knowledge and belief, true, accurate, and complete
lbased on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
Ltd I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part if (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit 1 will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times,
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.
_L/JK
Name of Project (m t match Ala)
Ily Responsible Organ
_ A, _ _ s ,
Legally Responsible Person
Title of Legal R IT
ponsibl
*Sig ure
C�-_SS 1 C. cA__ Ab
*Print Name and Title of S /
21!6, !�q
Phone Number
< C1IHEY 4musrMatch B1)
march B2 & B3)
e Person (must match B3b)
an. I�lxpZ
Date
Cu ri Hurnonzea individual Differs from Legally Responsible Person
IMPORTANT NOTE: This farm 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 Part IV, Section B,
Item (6) of the NCG01o000 permit. For more information on signatory requirements, see Part IV, Section B, item (6) of the
NCGOl 0000 permit.