NCC213871_NOI Signed Certification_20210706

INCG01 Notice of Intent (N0[) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original fof m to the AFC 0 E M L R Stormwater Program (with S 100 check if paying by check) at:
Division of Energy, Mineral & Land Resources 6tcrmwater Prograrn
512 N. Salisbury Street, fig^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU BAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC Geri ei al Statufe 14.3-215,68 (l), any person who knowingJy mokes ony false statement, representation, or
certrfr`cotion in any application, record, r'epor't, plan, of other document filed or required to be malntar'rred under this
Article or a rule impiemen tiag this Article ... shall he guilty of a Floss 2 misdemeanor which may include a fine not to
exceed tern thousand dollars ($10,CW).
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 pena[ties incurred due to Vio[ations of this permit.
The information subnn itted in this No is, to the best of my knowledge and belief, true, accurate, and complete
Lased on my inquiry of the person or persons who manage the system, or those persons directly responsible for
�gatherin;g the information.
iJ I will abide by all ccnditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan_
—+ I f t h e approved Erosion and Sediment Control Plan is not compliant with Part II ( tormwater Poliuticn
Prevention Plan) of the NCC010000 C,a, eneraI. Permit, I will non ethe[ess ensure that all conditions of Part II of the
it are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable in the same rnanner as an
individual permit.
Name of Project (must match Al a), C
Specific Lot Numbers (must rnatch Alb):
LegaiIyResponsible0rganizationaIEnt[ty(must match81):
Legally Responsible Person (must match B2 & 83).
Title of Legally Responsible Person (must match 83b): c_.-� y\
Narne & Title of Signed if Authorized Individual
DIfFers from Legally Resonsible Person: p /-e'lne-
Phone Nurnber: i
Person or Authorized Individual
Date ..'
lAr7POfiTANt NOTE: This form must be signed by a responsible corporate affirer th at owns or operates the construction activity,
such as a presrden r, secretor}; treostrrer, or vice president, of a manager that is authorized in accordance with ?art r v, section 8,
Item (6) of the NCG010000 permit,