NCC215436_NOI Signed Certification_20210930

NCG01 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the elec&xw* N®I.
Then, mail the original form to the INC 0ENILR SWffmW2itesr Program (ta iffi .$1D0 dwk if paying by check) at:
Division of Energy, Mineral & Land Pesources 5tormwater Program
.512 N. Salisbury Street, 6", Floor (Office 644K)
1612 Mail Service Center
(Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
1r e.p.. ,:
�: c;..�r.tx� • rr� r-r.ra�rr:+.r;; "rx r, J�r.r r:r'r: r: :r==..�.� r.n:�.:�;, - ..r r r..�_•. .. r, rn r.._ ..,. , i. ; .;r' i::�
r':." y, J r. ;. G:: "-,qk;r( .'{ ... >,. ,{.. :. Y r.^ :c. r: sY", �: r: :e r'�rAl., �..r r' k
r F- Fr r .r n;i'rr. 11! i
Under penalty of law, I certify that (check all boxes to indicate your agreement):
1 am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
�i The 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
gathering the information.
I will abide by all conditions of the NCG6I.0000 General Permi; and the approved Erosion and Sediment Control
Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NC6010000 GEneral hermit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the XGUlnnnn C-c-pral 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.
Now of Pn*xt (my& ma" •r t4e%r kkw-,*s
S is Loft Ills (ownt a ):: N A
j I ( Bli: NEsr-LegAyl�-t-
R ble n (a tdma/ 82 & = C�Ai ` W ny o
1fltYe of Legalllly Neer re I� �n mUA%(+ 2
Mww & Tide of iilf In&w-dw1l
Differsit Legft Respum-6k persm
sronaWre of LegAy Vl e Permn or Awkmked Irrc wdual
1117,151z l
Date
* ( try: aatlWe;sd��� rv� BElse�im�a
alsoVeamw. o r wiae orasmns9w6*t•as anduwked in evowdowx uftPat #VYSwam 8,
Gf