NCC213496_NOI Signed Certification_20210630

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic NO|.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral 8'Land Resources StonnvvaterProgram
512N.Salisbury Street, G*Floor (Office 640K)
1612Mail Service Center
Raleigh N[Z7699'l612
DO NOT MAIL THIS FORM 0RPAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED ASCOMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR122'22]
Per NC General Statute243-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$1LlOOO>.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for 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.
| will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
U� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions ofPart ||nfthe
permit are met nnthe project atall times.
'K | hereby request coverage under the NCGO10000 General Permit and 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.
t.
Name of Project (must match Ala): 6c; ee �ei A k T
pecific Lot Numbers (must match A2b):
Responsible Organizational Entity (must match 81):
Legally Responsible Person (must match B2 & B3): fi-C � 1>0 4scwl *'
Title of Legally
Nanoe& Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number
4-ZC- -
Signature �of Legally 1�1
Person or Authorized individual
� ~3 — Z~Z
Date
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such osopresident, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,