NCC215266_NOI Signed Certification_20210927

NCG01 Notice of (intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to th=2 NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Er ergy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,1 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR P YMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE C MPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 12-2,22]
Per NC General Statute 143-215.6E (i), a y 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 Artic! ... shall be guilty of a Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars ($10,000).
iJnder penalty of law, I certify that (chec
0 1 am the person responsible for
.permit, and for any civil or crimi
�f The information submitted in th
based on my inquiry of the persi
gathering the information.
E/ I will abide by all conditions of ti
�iPan.
N/f If the approved Erosion and Sed
Prevention Plan) of the NCG010i
pelmit are met on the project al
!hereby request coverage under
permit will constitute the permit
individual permit.
Name of Project (must match Ala):
Specific Lot Numbers (must match Al
Legally Responsible Organizational Er
all boxes to indicate your agreement):
ie construction activities of this project, for satisfying the requirements of this
al penalties incurred due to violations of this permit.
NOI is, to the best of my knowledge and belief, true, accurate, and complete
or persons who manage the system, or those persons directly responsible for
NCGO10000 General Permit and the approved Erosion and Sediment Control
-rent Control Plan is not compliant with Part 11 (Stormwater Pollution
00 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
all times.
the NCG010000 General Permit and understand that coverage under this
requirements for the discharge(s) and is enforceable in the same manner as an
must match B1):' 1
ally Responsible Person (must ma ch B2 &
Title of Legally Responsible Person (nr ust match B3b
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Pers n:
Phone Number: p
1
gnature of Legally Responsibe Person or Authorized Individual
0- Z
Date
* IMPORTANT NOTE: This form must be sig ed by a responsible corporate officer that owns or operates the construction activity,
such as o president secretary, treasurer, a vice president or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 permit.