NCC215583_NOI Signed Certification_20211012

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 the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, 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 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
Per NC General Statute 143-215.6E (i), any 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 Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
❑x I 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.
® The information submitted in this NOI 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 NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
IN If the approved Erosion and Sediment Control Plan is not compliant with Part II (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.
❑x 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.
Name of Project (must match Ala): Hinsdale Tin kerbelI Storm Drainage Improvement Project
Specific Lot Numbers (must match Alb): Please see next page
Legally Responsible Organizational Entity (must match Bl): City of Charlotte
Legally Responsible Person (must match B2 & B3): John Keene
Title of Legally Responsible Person (must match B3b): Project Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 980-293-2086
10/05/2021
Signature of Legally Responsible Person or Authorized Individual Date
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.

Parcel Number
Tax ID Number
2
179-054-15
4
179-054-13
5
179-075-52
8
179-075-49
17
209-073-02
19
209-073-06
20
209-073-07
21
209-073-08
22
209-073-11
23
209-073-10
24
209-073-09
25
209-071-09
26
209-071-10
27
209-071-11
28
209-071-12
29
209-071-13
30
209-071-14
31
209-071-15
33
209-071-03
34
209-071-04
35
209-071-05
36
209-071-06
37
209-071-07
38
209-071-08
41
209-073-14
42
209-073-15
43
209-073-16
48
209-072-22
49
209-072-21
54
209-072-03
55
209-072-04
61
209-091-06
62
209-091-05
63
209-091-04
64
209-091-03
65
209-091-02
66
209-091-01
67
209-104-26
68
209-104-25
69
209-104-24
72
209-104-21
73
209-104-29
76
209-104-20
77
209-104-19
78
209-104-18
79
209-104-17
80
209-104-16
81
209-104-15
89
209-104-07
90
209-104-06
92
209-104-04
110
209-091-13
116
209-105-23
Parcel Number
Tax ID Number
145
209-103-06
149
209-103-40
150
209-103-11
176
209-103-25
177
209-103-24
179
209-103-22
180
209-103-21
193
209-122-09
194
209-122-11
195
209-103-18
196
209-103-17
197
209-103-16
211
209-123-02
212
209-123-01
213
209-123-03
227
209-112-59
228
209-112-60
229
209-112-61
242
209-124-46
243
209-124-24
244
209-124-23
245
209-124-22
246
209-124-21
247
209-124-20
248
209-124-19
249
209-124-18
250
209-124-17
252
209-121-10
253
209-121-11
254
209-121-12
256
209-121-14
257
209-121-15
262
209-121-03
263
209-121-04
265
209-121-06
266
209-121-07
267
209-121-09
272
209-124-06
273
209-124-07
277
209-124-11
278
209-124-12
292
209-124-30
293
209-124-31
294
209-124-32
295
209-124-33
303
209-122-10