NCC213841_NOI Signed Certification_20210628

NCG01 Notice of Intent (NOO Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
"rPTED AS COMPLETE.
ATAL) [40 CFR 122.22]
Per NC General Statute 143-215.6E (i), any person wha 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 ... 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 indicate your agreement):
I� I am the person responsible far the construction activities of this project, for satisfying the requirements of this
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 who manage the system, or those persons directly responsible for
gathering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan"
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of Part 11 of the
permit are met an the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala):
Specific Lot Numbers (must match Alb):
Ily Responsible 0rganizationaI Entity (must match B1)
ally Responsible Person (must match B2& B3)
Tit le of Legally Responsible Person (must match B3b
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:,��
Phone Number: _76r /I/ SL/7T
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signature at Legally Responsible Person or Authorized Individual
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Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordoncc with Part IV, section B,
item (6) of the NC6010000 permit.