NCC212769_NOI Signed Certification_20210511

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herb' s:
Print this form, complete, scan and upload to the electronic NOL
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 Stormwater Program
512 N. Salisbury Street, 61 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed fen thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
(� 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.
9 The information submitted in this NO] 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 these persons
directly responsible for gathering the information.
® I will abide by all conditions of the iNCG[?.1_€� 00 General Permit and the approved Erosion and
Sediment Control Plan. -
X If the approved Erosion and Sediment Control Plan is not compliant with Part Ii (Stormwater Pollution
Prevention Plan) of the r`a _ µ_ _ , € will nonetheless ensure that all conditions of
Part Il of the permit are met on the project at all tunes.
X I hereby request coverage under the ���ii: 6 '000ir Genera£ Petrnit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
saute manner as an individual permit_
Name of Project: Parking Garage (P378)
Legally Responsible Organizational Entity: MCB Camp €_ejeune
Legally Responsible Person: Neal Paul
Title of Legally Responsible Person: Deputy Public Works Officer
re:
*Print Name and Title of Signet! if Aftorized
Individual Differs from Permittee: Talia Prender ast PWD Civil Engineer
Phone Number. [phone] ext. 3242
Date:
* 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 in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 6, item (6) of the NCG010000 permit.