NCC211118_NOI Signed Certification_20210225

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print ibis forrn, complete, scan anti upload to the elC-c'tronic !=-
T hen, mail the original foni-i to the NIC DEWR Storillwater Program (with $100 checit if paying by check) at:
Ndision of Encrg'y, i"Ineral So Land Resources Sto1'11wvater Pro�ranl
512 N. Sahbury %-eet, 6-1" Floor (Office 640K)
1.61_2 Ii/!ail Service Center
Raleigh, NC 27699-:1.612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per 10 General Sfatute 1 3-215 6 : (ill, Gny Iverson ✓ ho knowingly males airy folse statemet t, rcpr esentotion,
or certUkoHon h? Lilly npplicatlor:, record, report, plan, or other document fiied or required to be rllaintaMed
render this Article or a We i;noemerl Ag this Article ... shall be gu lty of a'Class 2 misdemeonor which may
rrxNde a frrle not to e; teed tern thoosund dollars ($10,000).
Under penaljy of 1 ", ! ceAdy that Nheck all boxes to i:ldkMe yow Ggl'e'emem):
NI am the perscn responsible far the construction activities of this project for satisfykg the
regArements of this permit, and for any Aid or criminal penclties i 1C;!rred d€je to violat-ions of this
Gennit.
2 The ,hifurrat1on submitted In this NCH fs, to file beg of nnl,, knowledge a:'d. be!1c lrl`.e, accl',rate; and
cornQke lids p A manage - c c
1' ctt' ..'a nl�y li1y1111-�1 of ire jJel's4i1 CI ,cl"sOi1s ',: 11G ilGiia�c tliL s��_�� � I: Or t 1i,SC peI'.,o;i5
directly resporlsiNe for gathering the information,
f i lr hi abide kql ah conditions of the NCG010000 General Permit and the appl-oved Frosiorl and
�,� Sediment Control Plan.
'S If the approved V doll and Scddnellr Col1vol Mail Is not comphant i4%i h Pw II 15LCIi m" ab's roIRMon
Prevention Puri) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
/ Pan H of the permit are nlet on the project at all times.
"J I he1sby request coverage under flit- NCGO10000 General Permit and understand that coverage ranger
IN ri::nult vAl constitwe the permlt requirements for the discharge-(s) and Is eiif rceable to the
same rnarinei as an inn V dLlal permit.
Narn&of 1'I'C M: C 9—
Legally Responsible Organizational Entity: � � � C�rts��-� �-� � V► 1.�
Legally Responsible Person; —� `1f`[& ~------.---___�_ ��---- ----
We of Legally Responsible Person:
"Signature: _-----._-_.—_! !aLeT Z� a
"Print Name WON
iN 01 S jned h AL'Ll ONed
Phone 1 undrer: C \I
ir,':l ORL: .,0_. ; •... .... an L I - ;L:.A by ti rC i.i Lll,,.;;J, Li:.!'�i '..'i_ v,Jr.- LI: L': _ ,
1
piiii€(:€r":ri+ ri; f,(c'v (i:.Xlcr vr�i;l:-�}ii rv�..�rl i+ir,? c,, An] .�. Gj lll,t NRY560111 Palm&