NCC213831_NOI Signed Certification_20210702

NCGO1 Notice of Intent (NOI) Certification
Form
Directions:
Print this form, complete, scan and upload to the electronic NO
.
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 Progra
512 N. Salisbury Street, 611 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 143-215.6E (i), 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 ... shall be guilty of a Class 2 misde
meanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Underpalty 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 s
tisfying the
requirements of this permit, and for any civil or criminal penalties incurred du
to violations of this
permit.
The information submitted in this NOI is, to the best of my knowledge and bel
ef, true, accurate, and
complete based on my inquiry of the person or persons who manage the SyStE
m, or those persons
directly responsible for gathering the information.
�
L�( 1 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 II
(Stormwater Pollution
P vention Plan) of the NCGO10000 General Permit. I will nonetheless ensure
hat all conditions of
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understZ
nd that coverage under
this permit will constitute the permit requirements for the discharge(s) and is
nforceable in the
same manner as an individual permit.
Name of Project: Vv % $pn N-ache fY\ el�t .-;_ 1
I
Legally Responsible Organizational Entity: �l�J, , so'l (A OQ
CAG�-�-,
Legally Responsible Person: 1- an(atANA'
Title of Legally Response le Pers •j
*Signature: Date:
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: L,- 3 T —
IMPORTANT NO'1 E. This form must be signed by a responsible corporate officer that a
s or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager
that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the
CG010000 permit.