NCC210877_NOI Signed Certification_20210315

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Prin", this form; complete, scan and uliload to the electronic NO!.
Then, mail the original forth to the NC D[IVILR Stoi-nlwai"er Program (%vith $100 clieck if Baying bit check) at:
Diuision of EnC:My, Wlierai & Land Resources Storinwater Prograrn .
512 N. Salhury Street, 6-1" Floor (Office 640K)
1612 F,fiail Service Center
Raleigh, NC 21699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per ,'VC Genergi Stott-, te 143-215.65' (i), ony person ✓ hc; knoilvingly yokes any folse stoz'erneni, repreSten otion,
of- cer-tifiCotion in any app"icctio., , record, report, plop, or other a'oCui77ani f ifed or required to be nlohitahied
under this article or a rule inipiemenHng fhl ArHde ... Snail be gi Nol Oj a'Closs 2 misoen-tteono?" i4thich may
include a file not to eyceed fen thousa!ld dollars f$IQOOQ
Under per:Q of lavL1, l ce: _if'',' :~hat (chec:, all boxes to Mdicate your agmen-in `_):
I am the p`rsGn i-EsponsiblE for the construction activitks of thk pmoc't, kv sat!ST)%ilig'ih2
replement of This permit, and for any AN or criminal per!clties incurred dlue to vicniat!ons of this
!' The in--onnatlon submiM In this NON is, to the (Jest of ivy Icno',vleC?ge and. hellEf, trUe, 2CCI.lrate; and
complat._. Wed cri ivy inquiry of the person or 1J2!s"s who manage the system, or thOSE- persons
directly responsible for gathering the infonvation.
i 'vvili abide by all Conditions of the NCG010000 General Permit and the app!-oved Erosion and
Sedirnent Control Plars,
u WE opNl"G'JEia Sci.:ili+cn'i, CDinll-oi Plan IS I1Gt C.Di1il.-itldlFi v,+ittt t-ol t fi iSL7i-!llltiiaicr Pollution
Prevention Plan) of the NCG010000 General Permit I vdill nonetheless ensure that all conditions of
Part 11 of the permit are niet on tsl.' project at all times.
I f!e.rEby request coverage under the NCGO10000 General Permit and understand [hat coverage under
this pe1-n-lit will cons"iti!te the per alit requirernents for the discharge' and i5 erlfoi CEa171C in the
saf]lE fli2rinec as an indivlt Ial pserivit,
Nlamaof i 1_ojert: E- i x1 , Ph odt 4 , Pu ..— 2Ck11SY1_ - ).6" Zi001 ,
Legailyr Responsible Cm-gJnhational Entity: ( 1. vi'"—O ;i 01-' - - 2-�3 -2 01
Legally Responsible Flemori: r3n&ram tAjlj ref -� ----------------_v�__
l V of Legally R:esp Amble Per _x-i:
Kgnature:----
'''Print klame arm{ i ire oy Syneo tj'f?!.?Morhe(E �
Phone Number: C�
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