NCC214824_NOI Signed Certification_20210830

,_
NCGO1 Notice of intent (N01) 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
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Program
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE
THE FORM. YQU MAILIM UST BE CO
MPLETED.WTH AN0 G I NAI GNATURE {NOT DIGlTAi.} [40 CFR
122 22]
Per NC General Statute 143-215,.6Ban (i)y person who knowingly makes any false statement, representation, or
certification i*n any application, record, report, plan, or other documentfi�led or required to be maintained under th
is
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 r)enaltv of law. I
i am the person r
permit. -and to
certify that (check all boxes to
esponsible for the constructi
ff -W
r any civii or criminai penalties i
indicate your agreement):
ft r -
on activities of this project, for satisfyingthe requirementsnf this
ncurred due to violations of this permit,
�y The information submitted in this N01 is, to the bes
. based on my inquiry of the person or person
gathering the i
will abide by ;
Plan.
nformationt
t of my knowledge and belief, true, accurate, and complete
s who manage the system, or those persons directly responsible for
conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) andis enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): Y��i'x (�
Specific Lot Numbers (must match Alb),.
Legally Responsible Organizational Entity (must match Bl):
Legally Responsible Person (must match 82 & 83):
Title of Legally Responsible Person (must match B3b):
Name & Title of Signed if Authorized Individual
IP
Differs from Legally Responsible Person:
Pone Number.., r
h
i
t
61
t
ignature of Legally Responsible Person or Authorized Individual
Date
ti,
-h
* IMPORTANT NOTE: This form must be signed by a responsible corp orate officer bl�at 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 !V, Section B.
Item (6) of the NCGO10000 permit.