NCC214715_NOI Signed Certification_20210831

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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, 6t' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (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, l certify that (check all boxes to indicate your agreement)-
I am the person responsible for the construction activities of this project, for satin ong the
requirements of this permk and for any c�vi1 or criminal penalties incurred dice to violations of this
permit.
® The informatiion submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete Lased on icy inquiry of the person or personswho manage the system, or those persons
directly responsible for gathering the information.
® I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment
Control Plan.
® if the approved Erosion and Sediment Control Plan is not compliant with Part 11(Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 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 requiremmuts for the discharges) and is enforceable in the same
manner as an individual permit_
Name of Project: Wayne Preparatory Academy -Phase 4
Legally Responsible Organizational Entity: WFCS Holdings, LLC
Person: John Cairns
Title of
*Print N
from Pe,
Officer
Phone Number: 612-986-8532 l
* IMPORTANT NOTE. This form 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 IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.