HomeMy WebLinkAboutNCC211802_NOI Signed Certification_20210329NCG01 Notice of Intent (N01) Certification Form
Directions
Print this form, complete, scan and upload to the electronic NOL
Then f mail the original form to the NC DEM LR Stormwater Program (with 100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, t� Floor (Office 4 )
1612 Mail Service Center
Raleigh} NC 27699-1612
DO NOT MAIL. THIS FORM OR PAYMENT
UNTIE. YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC Genera} Statute 14 -215, 6E l), orgy person who knowingly mokes any false statement, representotion,, or
certr icuti on in any application{ record, report, plan, or other docu en t filed or required to be maintained under this
Article or a rule implem en ti g this A rtficle ... sh all he guilty of a Floss 2 m isde eo or which m cy include a fineri o t to
exceed ten thousand dollars ($10,0001.
n d e Pe n a Ity of I a w, I ce rt ify th at (ch eck a I I boxes to i nd irate your agree m ent) :
i am the person responsible 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.
_ The Information submitted in this N01 is, to the best of my knowledge and belief, true, accurate., n d complete
based an my inquiry of the person or persons who manage the system., or those persons directly responsible for
gathering the information.
A i vvi I I a b ide by a I I cond itio ns of the INCG010000Genera I Perm it a nd the a ppro ed Erosion a nd Sediment Control
Plan.
.......[f the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 GeneralW r itr I will nonetheless ensure that all conditions of Part li of the
permit are met on the project at all tires.
I hereby request coverage under the NCGO10000 General Permit a rid 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):pf:0uOrAto �,,,,��'��T�-
5pecific Lot Numbers must match A3bj: �
Legally Responsible Organizational Entity (must march B1): nlie Iva& C' 0.0or If,/ C.
Legally Responsible Person (must match 82 & B3): 14112.�iL. � �(
Title of Legally Responsible Person (must match 83b):
Marne &Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: � � � � � Jam' �'ll
9E tip I qe�r i
'doo*01. a "Ism
Signature of Legally R ansible Person or Authorized individual Dat4
* IMPORTANT NOTE, 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 it; accordance with Part !V, Section 6,
Item (6) of the NCGOZOODD permit.