NCG210495_Signature Page_20210614

GC- L.C.,J NC b
NCG210000 N.O.N.
c) Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste generated per month) of
hazardous waste? REOFIVED
❑ No ❑ Yes
d) If you answered yes to questions b. or c., please provide the following information:' 14 2021
Type(s) of waste: UENR-LAND QUALITY
How is material stored:
oflOi ER 's
Where is material stored:
How many disposal shipments per year:
Name of transport 1 disposal vendor:
Vendor address:
18) Certification:
North Carolina General Statute 143-215.6 b (i) provides that:
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; or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
hereby request coverage under the referenced General Permit. I 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.
certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing: Gob Lr-t� L
Title: ll_J : Itl it
2
(Signature of Applicant)
6 lo1Zt
(Date Signed)
Notice of Intent must be accompanied by a check or money order for $100.00 made payable to:
NCDEQ
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