NCC215599_NOI Signed Certification_20211011

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NCG01 Notice of Intent (NOI) Certification Fo n
Directions:
Print this form, complete, scan and upload to the electronic NOl
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 checklif paying by check) at:.:
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 60, Floor (Office 640K) j
1612 Mail Service Center I
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPU ATION HAS Bi1EN AC41�TED AS COMPLETE.
,�E FORM YOU MAID MUST BE COMPLETED WITH AN ORIGINAL SIGNATUR9 (NOT D IG)ITAL) (40 CFR 122.2
Per NC General Statute 143W215.6B (1), any person who knowingly makes any false stateme t,'representation, or
certification in any application, record, report, plan, or other document filed or required to b maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not io
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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.%
P/The information submitted in this NOI is, to the best of my knowledge and belief, tr�e accurate, and compete
based on my inquiry of the person or persons who manage the system, or those persons directly responsibie for
�aathering the information,
I"I I will abide by all conditions of the NCG010000 General Permit and the approved Er son and Sediment
pp. � Control
Plan.
L�f If the approved Erosion and Sediment Control Plan is not compliant with Part If (Stoj mwater Pollution
Prevention Plan) of the NCG010000 General Permit. 1 will nonetheless ensure that a,il conditions of Part if of the
�rmit are met on the project at all times.
L'J I hereby request coverage under the NCG010004 General Permit and understand that coverage under this l permit will constitute the permit requirements for the discharge(s) and its enforceab�le, in the same manner.!as an
individual permit.
Name of Project (must match Ala):
Specific Lot Numbers (must match Alb): /C) s
Legally Responsible Organizational Entity (must match B1): 62dCr.—
nsible Person (must match B2 & B3):
Title of Legally Responsible Person (mustmatch B3b): 127,—, r?ci �e r' i
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Name & Title of Signed if Authorized individual /
Differs from Legally Responsible Person: �a'I�1 t70Gt1,51c , /'f/f�, h,� p, p �-• j
Phone Number: 3l3 — 6-oo — -7a41 5,
or Authorized individual
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 permit.