NCC213780_NOI Signed Certification_20210625

NCG01 Notice of Intent (NO[) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NUf.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if poyrnq by check) art
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statenrorrt, repre-,errtetirsn,
or certification in any application, record, report plan, or other documertt filed or required to be momtawwd
under this Article or a rule implementing this Article ... sholl be guilty of a Gass 2 misdemeanor "Kh rrMoy
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement).
X I am the person responsible for the construction activities of t1- - ;;att, for sartisfying the
requirements of this permit, and for any civil or criminal Pena ' incurred due to viafabomof lbws
permit.
The information submitted in this NOI is, to the best of my knc;.we. _ :: e`, true, accurate, arm
complete based on my inquiry of the person or persons who manage the system, or those oeersorrs
directly responsible for gathering the information.
X I will abide by all conditions of the NCG010000 General Permit and the approved Ero:. r
Sediment Control Plan.
X if the approved Erosion and Sediment Control Plan js not come
Prevention Plan) of the NCG010000 General Permit. I will nonetr,e:e„
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 caaera:<_= ;ar
this permit will constitute the permit requirements for the discharge(s) and is enforceable in th*
same manner as an individual permit.
Name of Project: Duke Energy Folkstone - Jacksonville Laydown Yard
Legally Responsible Organizational Entity: Duke Energy Progress, LLC T
Legally Responsible Person: Randy Velid
Title of Legally Responsible Person: Director, Transmission Permitbng
"Signatur - ,'cf__ � ` L �✓' Crate:
*Print Name and Trtl4 of Signed if Authorized
individual Differs from Permittee:
Phone Number: 704-382-2741 7b s?-r 51 07
IMPORTANT NOTE: This form must be signed by a responsible corporate officer shot owns or operates the
construction activity, such as a president secretary, treasurer, or vice president or a rncager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 pertrut.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the MC601 WX ;y— -`