NCC214331_NOI Signed Certification_20210728

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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 Program
512 N. Salisbury Street, 66 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 MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE [NOT DIGITAL) [40 CFR 122.22i
Per NCGeneral5tatute 143-215.6E (i), any person who knowingly makes anyfalsestatement 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 misdemeanor which may include a free not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
EK 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.
® The information submitted in this NOI 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 persons directly responsible for
gathering the information.
El I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
K If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 G neral Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
® 1 hereby request coverage under theNCG010000 General PerWit 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): Dynamite Creek Mitigation Site
Specific Lot Numbers (mustmatchAlb):
Legally Responsible Organizational Entity (must match 81): Wildlands Engineering, Inc.
Legally Responsible Person (must match 62 & 83): John Hutton
Title of Legally Responsible Person (must match B3b): Vice President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone NumllOrf 191
onsible Person or Authorized individual
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IMPORTANT ROTE: This folm must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordance with Part 1V, Section 8,
Item (6) of the NCGO10000 permit.