NCC212631_NOI Signed Certification_20210511

NCG01 Notice of Intent {NOIj Certification Form
Dirertidns:
print rhis form, complete, sfan and woad to the electronic NDL
Thee, mail the esil lnal dorm io the NC DEMLR Slormwater Program (with S100 check dpoVifW by ehec#) at:
Division of Enna{, Mineral $ Land Resources Sti rmwvser Program
312 N. Sahsbury Straet, 6- floor IDfrire G4W
1632 Mail Service Center
Raleigh, NC VG944G12
DO NOT aAAIL THIS FORM DR PAYMENT
tJWnL VDVIt APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Pew Generol Starufe 14J-225.fi6 N, "oerson who knoaaa¢7ymdtes on y fpr5e 5warnent, rcpresrnrar+on, Of
[rr_gif* i*n in any agartihcdicK record, rep od, plot, or ofher docummr JAW or regeirtxd to be maiinroihed vi-Wr CRY
Ariick or a tyre M Wrmenting Ods Amick ... shall be quJty of a CA= 3 misdemewsor which moy ihdude a rrne not CO
eneed ten Oft,"Ad do 41m^s t$10.0WJ.
Under penalty of law. I ceraily that [checkall baaes to Indicate year agree menial:
t am the person responsible for the convirucWnactivities of this project, for sathfyrrr$ the requirements or this
pKmit, and forany;lull er trimznal penalties inclined dr•e ro Mowions of tills permit.
" { The informsWis subrthhSed' in this N61 is, to the best oL my k.wwedgr and belief, true, accurate, and complete
based on sop Inquiryof the person or persons who manage the system, or those persons direttty mwendble for
gathe,ing the infol IVsaiion-
r wit ahicir by all ronditiom of the L1r„�ii�l (ienMal Permiland tree approved Esos.on and Sediment Control
Plan.
li the approved Erosion and Sediment Control Plan is rntt compliant with Part 11(Stormwaler Pollulion
Pr(vrnt$on Plan) of the NNQWjrlpr7jge_ncral Permit I will nonetheless ensure that all conditlona of Part it of the
perrta are nw on the prajrtt r all tomes.
I hereby request coverage under the r;€Ga] ootlo ggneral PfrmA and ueldersta td that Coverage under 11n11
permit win constitute the permit requaernrnta for the dischargcEsj and is enforceatile in the simt manner as an
indrvidualpermit. i 1 �] 4 r
Nnr•rn of pmla.rt (mast match a ]aL• r t"t A !n e? 1 } r. r1r7� to L n
SotciflrLot NumbersdmvstmatrhAIM: 49,
Ot
rmfrh62F IC& HnmF*4 L/-c
Person brudd match 62 &
Title of Legally Rksponsible Person;rrurst march B361: r t« y i
Marne & Title of $igned if Authorised Individual
f}ifl'ers from tcg2Ry Responsible Person:
or Authorized IntlMdual
AWPMTAAr;rNMZ rNi farm nW1r be Ajpi a rrspvrsibk t rl"fore offiver thot owns or omiltes the cam3nxtion ocrMty,
.wall ax o prrs�drnf. serrrtarl'. � ar firer presider(, wo mmolTrrdxtt;s CCKtwrzrdyi a€ror4anfe wdrh Port N, Snrrllr 9,
gem f6JAfrileN=ll rptrrnir.