NCC215034_NOI Signed Certification_20210908

Notice of Intent Certification form
Directions:
Print this forma, complete, scare at W upload to the electronic O$,
Then, mail the original fortt'a to the NCIDEM1.11 Sfnrmw+rter P tam with 5100check if paying by e ft) at.
Division Of Ewer y, Mineral& Land Resources Stormwater Program
rn
512 N. Salisbury Street, 60 Floor (Office i
1611 Mail Sete Center
Raleigh, NC 27699-1612
00 NOT MAIL 'l IS FOW OR PAYMENT Chit yOUg AppUCATloN,4AS
E PCOWtEM
F - MWT 1W, COMPLMD W"V' AN 04141AW,J
Per NC 60neral Statute 143415.6B gai , any Poison who knowinglI, makes ativ fake statement, r presenration, or
cerhcart r`rr anyQPOCOriart, record, fe t, Plan, or other dt urnent filed nr° required to be rr ointorr d seceder this
Artie 0r 0 rule imPlerttent rrg Ws Artick, .. shrill he guilty Of a Clasp 2 misderivanar which may Inches e o frie not to
exceed tern thousand donors 10, . ),
Under penalty of lawn, i certify that all boxes to indicate your a e e )
i am the person responsible for the construction activives Of this project, for satisfying the requirements of this
Permit, and for any civil or criminal penalties incur red due to violations of this permit.
IS The information submitted in this Not is, to the best of my knowledge and belief, trice, accurate, and complete
based on mar inquiry of the person or persons who manage the stares, or those persons directly responsible for
gathering the information..
l will abide by all conditions of the C� $ ,fin rt r fly and the approved Erosion and Sediment Control
Plan.
LA If the approved Erosion and Sediment Control Purr is not compliant with part It torrnwater Pollution
Prevention Plan) of the is Q, i C S'n rr l l will nonetheless erasure that all conditions of Part li of the
Permit are met on the project at all times.
IN I hereby request coverage under the f t etas tl Perreat and understand that coverage under this
Permit will constitute the Permit requirements for the discharge(s) and is enforceable in the same manoarjs age
individual permit.
Namw Of !TJ5t mar t°match a uncap 230kVLine
Specific Lot Numbers cast match d):
i ally bl i3r aniztil miry rt3usr t intake Energy Progress, LLC
a
ells e Oaaslbie Person rrtr t h a� Reidy Veltri
Tits of t aiiy Responsible Person t eIatrhi!
b !Mdor of Transmission
Name & Title of Signed if Authorized individual
Differs from Le � l!y )Onsible Permian,
Phone Number,
.�,.�� tcrr of iea Pis sibir,� Pura �sr l�trthoriad iradlvacluai _.�.M "_", ate
ThisPfm Must d by ar
sane as a PmAkht secretary, troauger, or v t er amarvVe that 0 duchorked lea r wrtrr Part 1 , ' ra d,
Item (d) 4 VV 1ifCW100W,