NCC214552_NOI Signed Certification_20210811

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOL
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,61'Floor(Office 640K)
1612 Mail Service Center
Raleigh,NC 27699-1612
i
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement,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 fine 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 satisfying the
requirements of this permit,and for any civil or crin;inal penalties incurred due to violations of this
permit.
The information submitted in this NO' ,., . -< t,i '; ! . 1v.1,,,dge and belief,true,accurate.and
complete based on my inquiry of the IAge the system,or those persons
directly responsible for gathering the
I will abide by all conditions of the t�f_i�tt' tree°approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Co °' ::F i. , m;:;ii,nt with Part i1(Stormwater Pollutiori
Prevention Plan)of the NCGO10000 GenNr_3_ �prr+ r :Lw;l,,onYti�eless ensure that all condition,cat
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 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.
NameofProject: CLk6VAL S' &71✓Ifl*J ioT 23 F-(- ONl-`1
_Legally Responsible Organizational Entity I/41 A"I'J �IY1 S d F GOA T r l�+t
_Legally Responsible Person, M rr�q GF)VRA
Title of Legally Responsible Person: 9vlW1 P(1- c I l i�1'�("7
•Signature• � ti
-Print Now wW Title of Signed If Authorized Individual
Differs from Permhtee:
Phone Number. C-7 04)3 61 —-7 4 �
•/Timm amour This form must be signed by a responsible corporate officer that owns or operates the
construction actfvity,such as a president,secretary,treasurer,or vice president,or a manager that Is
autltonized in aoaordarxY with Port/V,Section A Item(6)of the NCG010000 permit
For more kftirnmitilion on sanatory nrqu ernent4 see Port W,Section A!tern(6)of the NCG010000 permit.