NCC212363_NOI Signed Certification_20210429

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy,Mineral & Land Resources StormweterProgram
512N.Salisbury Street, 6*Floor (Office 64UK)
I612 Mail Service Center
Raleigh NC2769Q1G12
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute143-215.6B (i), any person who knowingly makes anyhalse statement, representation, or
certification inany application, record, report, plan, or other documentfiledmrequiredto be maintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$rL\UOD/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Jd I am the person responsible for the construction activities of this project,for satisfying the requirements ufthis
permit, and for any civil or criminal penalties incurred due to violations of this permit,
X The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
41 | will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
Z If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit | will nonetheless ensure that all conditions ofPart ||ofthe
permit are met onthe project atall times.
| hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the dischar8e(s)and isenforceable inthe same manner asan
individual permit.
of Project (must match Ala): PNG - Mallard Mills
Specific Lot Numbers (must match Alb): N/A - Linear Pipeline Project
Legally Responsible Organizational Entity (must match Bi): Duke Energy - Piedmont Natural Gas
Title of Legally
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
PhoneNumber 704-591-1743
Responsible Person orAuthorized Individual
*�ORTANTNOTE., This form must be signed by a responsible corporate officer that owns moperates the construction activity,
such oaopresident, secretary, treasurer, orvice president, oromanager that isauthorized /naccordance with Part IV, Section 2\