NCC214706_NOI Signed Certification_20210818

NCG01 Notice of Intent (N01) Certification Form
Directions
Print this farm, complete, scan and upload to the electronic N01.
Then, mail the originsl farm to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Miners! & Land Resources Stormwater Program
512 N. Salisbury Street, 6 -h Floor (Office 640I{}
1612 Mail Service Center
Raleigh, NC 27699-1612
DO N07 MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED, -,4N ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 12212]
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any pppfrcation, record, report, plan, or other document filed or required to b e mairttarned under this
Article or a rule implementing this Article ... shall be guilty of ❑ Class 2 misdemeanor which may intrude a fine not to
exceed ten thousand dollc7rs ($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 criminal penalties incurred due to violations of this permit.
The information submitted in this N01 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 systern, Or those PerSDCiS directly rPSpDilSlI3Ie for
gathering the information,
I will abide by all conditions of the NCGO10000 General hermit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Pfau is not compliant with Part I! (Stormwater Pollution
Prevention Plank of the N'CG01000(} General Per-mit, i will nonetheless insure that all conditions of Park 11 of the
permit are met an the project at all times.
I hereby request coverage under the NGG010000 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 Al,o)* -..� 4Z31�O- S `��i � :Z= � =- c='�•{�= �-- � } s-� ���`,.�
Specific Lot Numbers must match A1bj:
Legaf�y Responsible Organizational Entity (must match 8l):r
Legally Responsible Person(must mach B2 & B3):
Title of Legally Responsible Person (must match B3b):
Name & Title of Signed if Authorized Individual
Differs from legally Responsible Person:
_..Phone Number:
Signature of legally Responsibl son or Autharit�c lIivid ua
f V"k e,>r
Date
'� rr
poste officer that owns or operates the construction oct{r ,
such as a presiders t,, secretary, treasure r, or vice presider t. or a mangy ger that is authorized in accordan ce with Part I V Se c tion B,,
Itor of the NCGO10000 permit.