NCC214261_NOI Signed Certification_20210727

NCGO1 Notice of Intent (NO!) Certification Form
Directions:
Print this farm, complete, scarf and upload to tbe electronic NOL
Then, mail the original form to the MC DEMLR Stormwater Program (With $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources storrnwater Program
51.2 N. Salisbury Street, 6,h Floor (Office 640K)
1612 MaH Service Center
Raleigh, NC 27699-1612
0 NOT MAIL`l HIS FORIV OP. PXIME T UNrl" YOUR APPLim EON HA5 SU?,4 ACCIPT D AS COMPLETE.
TMF- FORM YOU MAIL. IMURSE COMPLE f'F0 Wfrh AWOMNAL 5546WRE (NOS' D161TAQ 140 U 12?--22
Per NC GeneralSteatute 143-215.6& f& any person who knowirgly makes uny false statement, representation, or
certification in any application, record, report, ,elan, 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 ($10,0001_
under penalty of law, t 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.
50- The information submitted in this NCt 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 persotls directly responsible For
gathering the information.
1 wIl abide by all conditions of the N G0110G30 General Permit and the approved Erosion and Sediment Control
Plan_
if the approved Erasion and Sediment Control Flan is nod. compliant with Part P (Starrnwater Pollution
Prevention Plan) of the NCGO100-0i0 Gsmer-ai Permit, I will nonetheless ensure that all conditions of Part li of -the
permit are met on the project at all times_ -
10000 seen: ra! De n•i and understand that coves anderth s
1 hereby request coverage under the ;�;C"�,:, v:s�•,:. _ ., coverage • ,
permit will constitute the permit reciuirement� far the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala). .IVY =Ftk 0 0;,J
Specific Lot Numbers (must match Alb): ���i��G„�• !�!°��•7' €.t� ,� � j�tla.Fi� � �1
Legally Responsible Organizational Entity (must match 131): .Zlf l A V �
Legally Responsible Person (must match 82 & B3): jop.1A j.� e
Title of Legally Responsible Person (must match 63b)-
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person-
Phone Number: -�>)
Signature 0. Legally Responsibly: Person or Authorized Individual Date
IMPORTANT NOTE: This form roust he signed by a responsible corporate officer that owns or operates the construction activity,
stacb as a President secretary, treasurer, Or Vice president Ora Manager that is authorized in accordance with Part N, Sections,
Item f6) of the NCG010000 permit