NCC212400_NOI Signed Certification_20210512

NCGO1 Notice of I
t (NOI) Certification Form
Print this form, complete, sca
Then, mail the original form to the NC DEMLR Star
Division of Energy, Mineral &
512 N. Salisbury Str
1612 Ma
Raleigh,
actions:
and upload to the electronic NOI.
iwater Program (with $100 check if paying by check) at:
and Resources Stormwater Program
et, 6t, Floor (Office 640K)
Service Center
C 27699-1612
DO NOT MAILTH S FORM OR PAYMENT
UNTIL YOUR APPLICATION WAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who k owingly 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 ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to ind icate your agreement):
1 am the person responsible for the construction activities of this project, for satisfying the requirements of this
f permit, and for any civil or criminal penalties incurred due to violations of this permit.
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 wh i manage the system, or those persons directly responsible for
gathering the information.
l"J I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
LEI If the approved Erosion and Sediment Control PI n is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements fc r the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala):
L,4Nc D6.j ftfZA-,, S 6�tm5c- Z-
Specific Lot Numbers (must match Alb): q 1
Legally Responsible Organizational Entity (must motcf B1): 1,11FIiil1 i'Lf 49-W-Wcm6n�
Legally Responsible Person (must match B2 & B3): �JUuS4-1fJ T� UNA)
Title of Legally Responsible Person (must match B3b): OW N
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: l 3n — l9 I6
ure of LWl?Responsible Person or Authorized Individual
02
Date
* IMPORTANT NOTE: This form most be signed by a responsi le corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, o a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 permit.