NCC215439_NOI Signed Certification_20210930

NCG01 Notice of Intent (N01) Ceitificiltion form
Directions:
Et@ s,3'1 3 iJ upioad to the cicclronic NOI
TMwst, ma; — n - :� : t' = CL.7 MLR StoFnwjter Program (s%ith S 100 chick if baying by check) at:
Derision of Eni-g,. V ner31 5. Land Resources Sturmwater P►ograrn
512 N. Sa'tsbury Street. 6- Floor (Office 6-10K)
1612 Mail Sentce Center
Raic:gh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED As COMPLETE.
THE FORM YOU MAIL MUST 9E COl'.IPLETED VJTH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 crR 122.221
Per NC Generol Stoture 1»3-215.63 (t), any person »ho knowincily makes any false statement, representation, or
eertrf►cation rn ony application, record, report, plan, or other document f+fed 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 (510,000).
Una cnalty of law, I certify that (check all boxes to Indicate your agreement):
71 am the person responsible for the construction activities of this project, for satisfying the requirements of this
/ prrrn;t, and for any civil or criminal penalties incurred due to violations of this permit.
Thrt information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
�alherinp, thc. information.
J I will abide bi all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Pl,,rn,
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (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.
Y I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
rJame of Project (must match Ala): ��keC�,��e� 1G�enllcA� 3 v , lA
Specific Lot Numbers (must match Alb): 1�) r\
Legally Responsible Organizational Entity (must match Bl): N G-' 1 QA-1 O " - rzr f 9n
Legally Responsible Person (must match B2 & B3): - %\ 6 j
Title of Legally Responsible Person (must match 83b): Ckr\J0,1 n�q-
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: /"6a% - 3CA\ - "Y`613
re of Legally Responsible fi—elotfAuthorized Individual
qr�?7 - �?f
Date
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as o president, secretory, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCG010000 permit.