NCC214550_NOI Signed Certification_20210811

NCGO1 Notice of Intent(NOI)CertificatiOm Fort'[
C6rrctons:
Print this f0+m,oe"iete,scan and upioa6 to the electronic NCII. 'eV DV check)at:
-rrr�.rnail ir+r w,gt•oMslo ad EhFAW,*Aneal&U;RersOure sWfInwa Proaf4rn
S12 N.Salisbuq street,6`Elour lOffice 640K0
1612 Mail SPrvlce Center
Ra9eW,,NC 276Sh-1612
00 NOT MAIL THIS F6RM OA PAYMENT
UNTIL YDalA ApPUCATION"AS BEEN REVIEWED AND ACCEPTED AS COMPLETE
An FJC fentrw'S'tatvre 143-215.66 Gb+*y mw wfro knowlnpry makes ony jn%se sratemerrr, Of
rertrfkarfon en NiY apOwtitw.rctord-repoM P�or other GbC�WnTrzt Jiftd Ar rrqu�'rtd to be maimlatriO uneler rlrit
,L,rkk Ora ruk A'srpkmentirg tM drfk*...Iliad"be 9uifty of Q CAass 2 MIS deMeaoOr which may frKju*a f inc rw[to
exceed ter,tAoufand Afars t9l(%OWJ-
Urrr,'. penatry raf law,i certify that IaheO all boxes to Inv kM*Your agreerrrent):
I am thR person respansibie for the(Onitnsctlan acthetles or th.s p roject,for satisfying the feruieements of this
pefml,and for any civil or crirri�lal per+ahies IntY+rad due to violgions of this permit.
`G The inrournation vArnMcd ki tl'� NOI is,to the best of my knovilledtte and Wlef,true„arcurate,and tompleLe
bastd on mY:'igk;ify9f the person Of pCrsons who manage the Sys tem,or tho sC peryoru diredly responsible for
gattierirg the lnfOrrnatlorr.
r swill atifde by all tonditiont of the l[[.Q1,4fk)0 General Kermit and the approved Erosaon.and Sediment Control
Plan.
If the ypgiroved Ermon and Sediment Control Plan Is not tUmplidn4 Wah Part It I$tormwater PollutlOn
Prevrrfion Plan]of the,NCG410QW General Permit.I Will nonathe-Im ensure that all conditions of Part 1101 the
perrmi are met on the project at al times.
i I hereby re,auest ubdcrage under the NCG010(M Genera4 Permit and understand that toverage under this
Y' perm.1 will constitute the permit reQuiremenis for the d=stharee{s)and Is enforceable in the vamp manner a3 an
Individual permit.
Na-L of Project I-Ltxr match Mai:_ '1'P.0 T+f F(rjn i
SpeeifkL6tHumber$irnusrmorclrAlb):_ ff ,' V
Let allyAesponsibte0fga^:tatianaI Entity jM01f n-0r h 821: `c(r 4
L aL Lft ns*ble Person�t motth 82&83i'
Tale of Le ally Responsible Person(fruit morch B3b):
Name S TWO of$tied if Aulhorited Irsdividuvl
[1df"from legally RcmnsiblePerson: /�
phone r;u J- ' g
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S e a,Legalf Respo ibl ' nor,AuthDrited I'Adfvidslal fate
thaaMtANT fP07f. Th"1101.111e11 6t signed bya rt sbtt cdrPa+OteVk"that awru oraAera+es t.mrLstnstian at7Me1.
s+A10 W o Prtsident se,rmy,Nrairrref,br w{ce prrritJM{,qr a monm7tr ih6[h
JF-(6f(If the NCGUId7t71Qlptrrvt. atrMiartrni ssdtlt Port fV,seams,