NCC214322_NOI Signed Certification_20210728

Directions:
Print this form, complete, scan and upload tothe electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnwoterProgram
5I2N. Salisbury Street, 6mFloor (Office 64OK)
161ZMail Service Center
Raleigh, NC 27699-1612
Per N[General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, orother dommentfiled orrequired tobemaintained under this
Article ororule implementing this Article ... shall beguilty :foClass 2misdemeanor which may include ofine not to
exceed ten thousand dollars ($10, 000).
1�r einformation submitted inthis N0is, tothe best ofmyknowledge and belief, true, accurate and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information,
O� | will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart Uufthe
permit are met onthe project atall times.
r�
=" ihereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): ELDRIDGE CONCRETE
Specific Lot Numbers
Legally
Legally Responsible Person (must match B2 & B3): TIMOTHY ELDRIDGE
Title of Legally
Nume& Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number: 910-594/9406
Signature of Legally Responsf$N Person orAuthorized Individual
IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such osopresident, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (@ofthe N[GU0000permit.