NCC215260_NOI Signed Certification_20210920

NCGO1 notice of Inte6t (Moil Certification Farm
all;i*ctions�
Print this,form; complete, wpanij Upload to the efectrunIc N01.
Then, mail the original form to the 14COEMf3i-Slernsw&tee Prag-am twlth $M check-rf Paftirng by. check] at:
gvision of Eriergyt, Mlperal1k fond Resources Stormwater Prnrsnl
517 N. Salisbury Street, & F1oar (Of#it:e 640K)
1512 Mall Seruice Oentar
0ai,igh,,WC 27669-161Z
DO NOT IVIAJI THIS FORM OR PAYMENT u�mL YpuR AP91LICATMN HABIEEN ACCENTED ASS WIVIKETE-
THE FokM YOU MAIL MUST BE CCFAFL�CD WfTHAN ORIGMAL siurtA3URE (N& alGlTAtJ t40 CFR 127- r]
per IVC Gerrerot Sla tote 14 3-,215.69 jiJr dny j "R who. gqu6 rir gJy rnQkeslrr3y atse s rdterrier ispr ntntiort, er
oenijicatiun in any -,application, remf4 repart, plan, 6r rcio"mehtriied this
Artkfe-or'O rWe irpplomenting this ArdcL- :.. -400II lr- guik of d: L7ass misdemeanar Which may+ frrrlude a firw not ' &Ceed tin thautond doltam.01000J.
Under-p&i0iy 6f I.avi, I certify that (check all bo>«es join irate your agreement).
I
I afn the Persim responsible fqr the tc)nsLrLktic n; ttivities pf ttris project, farsa#isfyir�6 tie requireincetts of Is
perry►it, and fo-r any tiuil ar crinnnal pen4tbey inc�rted due to ►rlvlations of this permit. I�
Tile Infoi-otatiun submitted 1h Mis Wi is, to the best of my kndwiMge and befief, true, a"urdte. And,compl' e
bawd on my 4jqulry of tht; pe:r4an flr per-wns wl}a manage th,e.SYs. em, or throe pe5.omlirectly rLnpon5ilbli iar
gathering Lhe InfprmakrVn-
I will attidiJ by all conditlonS of the SIC QiO❑OaCier<eral Pennit and the :oppro►+er1 Frosian and Sediment Coo MJ
I
Platt
If tht arpmvetl EresiQn inild 5edlmerrt Cflmr[.fl Rtarl I. na%i;Qmpltatit ur14h phri II {StnrirlWafi.ur Rollrrtiiitl
Pn�viUnlitui P12n) of tine NU31110=l Geller`0l Perdt.1 will norwtheless en$vre th-at all cundditans Gf Part II a he
pr, rmlt are rnM an the ptoJect it all firnes.
I herehy request rovemge un:derthe NC►sOU GEnLlral Permit anti uridewand that caxrerag*: under this
permit writ tonLotute the permlL require merrts fir titer d'tsvhatge(�f and is erif6rttabie in the sarrre manner - Zin
Individual permit
Name of Project oe�-
Specifk lot Numbers (rnust rrtrit0 Alb): �OW
I y.t Iil (.lrL
Legally RespoMtble Organizational E tityr rrrr�st tr+ardr �1�: �h —
Lego qy RespcSn&* �e .Pessan (rnrt5r Wtt{r B� & 931:
Title of Legally Ft2spr rv6h1e Person (mug match Wipl: �
Narne & T3tiie Of SigrrQ.d Jf Authorized Individual
DiFfers Irvm Legally Responsittle-P.$rsonrr•:
Phone Number-y +,p�
Signature of ga]ly geWuMible bate
+ 1MMftiAAFr• Fdatr; This farm rrrusr hP lrgaed by a resporgw corporotgvicer that own v or operaws-the rnnstnhttiod arfiit l.y,
suih a3 a prevdient; serirtu y, tewsar". �T P en2, jr,a manager treat is "thaerzed marrordnnee with PovrJV 5ectlt, 8,