NCC211166_NOI Signed Certification_20210312

Print this form, complete, scan and upload tothe electronic MD|.
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 Stormwa1erProgram
5120.Salisbury Street, 6'^Floor (Office 64OK)
161ZMail Service Center
DO NOT MAIL THIS FORM OR PAYMENT
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule imFylemcnLJ�n;ri this Article ... sh a // be &UiL�i o_ff a Class 2 m is dem eon a r wh ich m *4vin-M J.Am*g r�rxszwj
exceed ten thousand dollars ($10,000).
;2­1_1 am the person responsible for the construction activities of this project, for satisfying the requirements of thl
information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based onnnyinquiry ofthe person or persons who manage the system, or those persons directly responsible for
gathering the information,
~E]- | will abide byall conditions mfthe and the approved Erosion and Sediment Control
nan.
E]ifthe approved Erosion and Sediment Control Plan isnot compliant with Part U(StonmwaterPollution
Prevention Plan) ofthe er | will nonetheless ensure that all conditions mfPart Uofthe
permitnthe project atall times.
~�1�~-|herebyrequest coverage under the 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.
Name of Project (must match Ala): rLc-� K ­ _L�-
-Legally Responsible Organizational Entity (must match B1): I � ­� 4- �vc w. ­J_'� L' (_ (�
-Title of Legally Responsible Person (must match B3b):
Name & Title ofSigned KAuthorized Individual
-Differs from UResponsible
iMPORTANTNOTE. 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 Part IV, Section B,
Item (6) of the NCGO10000 permit.