NCC214149_NOI Signed Certification_20210716

NCG01 Notice of Inforif (N01) Cortifkstion Fran
fliter tlion%
Print This form, (ornplelo, usn Arid ufrlrr.rrl 16 the RLrNrAA trl►t
orJilin al form to the NC DCM1N r;IW MWOFf 1'rrptrarr, f.vrfl, ; Jfifr rt.vrlr ff prryir"i ►i/ r►-eki xr
Division of E nergy, Mineral IL I Arid Nostr►rres'rtrrrrrrawtxr Prr,%rxrr,
S 1) N Swllrbury Stroet. fr t IrxA (0"1'e wo,
161) M.111 ('81 vir a Tenter
N,rlrigh, NC 17WP 1611
DO NOT MAII TNIti FORM OR PAY MFNT UNTII YOUR A"LKATION HAS "IN ACJYTWA!&WONVITI.
THE FORM YOU MAIL MUST Bf COMPLETEO WITH A/V
Per NC General 5ratute 143 215 613 (1), any person who knowingly, makes ony false 001'ement, or
certification In any application, record, report, plan, or other document Idled or required to be mointorrw d under thri:
Article or o rule implementing this Article. sholl be guilty of a Class 2 misde_ mronor which maq axWe o f►rw not to
exceed ten thousand dollars ($10,000)
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 satrsfyrr►g the requaenwi"S of INN
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 co„Viete
based on my inquiry of the person or persons who manage the system, or those persons d►rectfy responsAWe for
gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Seditnettt Contra
Plan.
Z./If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part It of V1*
permit are met on the project at all times.
✓1 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 ar.
individual permit.
Name of Project (must match Ala): C 0-< <0 1-L M L c- ) -7
Soecific Lot Numbers (must match Alb): f %
Legally Responsible Organizational Entity (must match BI):
Legally Responsible Person (must match B2& B3): C-LI-ire( I���{ (�
Title of Legally Responsible Person (must match B3b): G w h t
Name & rrtle of Signed if Authorized Individual
Differs from Legally Responsible Person
Phone Number: 33 L" 61-jC'
r6' --) J�112'2z-1
— rgnature of ally Responsible Person or Authorized Individual Date
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction ocuvity,
such a-, u president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part iv, SCCTW B,
item (6) of the NCG010000 permit.