NCG140490_NOI Signature Page_20210618

NCG140000 N.0.1.
How many disposal shipments per year: NIA
Name of transport 1 disposal vendor: r,rA
Vendor address: N;A
Final Checklist
This application will be returned as incomplete unless all of the following items have been included:
❑ Check for $100 made payable to NCDEQ.
❑ This completed application and all supporting documentation. See Question 10.
}h ❑ If an Erosion & Sedimentation Control (E&SC) Plan is required from Division of Land Resources (Di or
local designee: documentation verifying applicant has developed and submitted that Plan to the governing
agency (required per 15A NCAC 02H .0138).
❑ Two (2) site plans depicting the site plan with numbered outfalls which indicate stormwater and wastewater
r outfalls. See Question 10.
❑ A county map or IJSGS quad sheet with location of facility clearly marked.
28) Signatory Requirements (per 40 CFR 122.22)
All applications, reports, or information submitted to the Director shall be signed and certified.
a. All notices of intent to be covered under this General Permit shall be signed as follows:
(1) For a corporation: by a responsible corporate officer. For the purpose of this permit, a responsible corporate officer means: (a) a
president, secretary, treasurer or vice president of the corporation in charge of a principal business function, or any other person who
pei forms similar policy or decision making funuliotrs foi the corporation, of (b) the manager of one or rnore manufacturing production or
operating facilities employing more than 250 persons or having gross annual sales or expenditures exceeding 25 million (in second quarter
1980 dollars), if authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.
(2) For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or
(3) For a municipality, state, federal, or other public agency: by either a principal executive officer or ranking elected
official.
Certification: North Carolina General Statute 143-215.6 Bl 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 doilars ($10,000).
I 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.
I 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: Anarety Owen
Title: Project Engineer
(Signature of Applicant)
2a. (p i b Zo Z 1
(Date Signed)
Page 7 of 8
SVVU-NCG14-NOI Last revised 8/01/2017