NCC215815_NOI Signed Certification_20211019

Directions:
Print this form, complete, scan and upload tothe electronic NO|.
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 StormwaterProgram
512N.Salisbury Street, GmFloor (Office 64UK)
1612 Mail Service Center
Raleigh, NC27698'1612
MAI
Per N[General Statute 14]�5.68(i),any person who knowingly makes onyfalse statement, representation, or
certification /nany application, record, report, plan, orother docunnentfiledorrequired tobemaintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$1(I000/.
Under penalty of law, |certify that (check all boxes to indicate your :
Er"'I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, 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.
-°~-- will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
c13r |ftheapprovedEmaionand6edimentCor¢no|P|anbnctoomp|iantvvithPart||(StonnwaterPoUuhon
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart Uofthe
permit are met onthe project atall times.
c*1-1|herebyrequest coverage under the NCGO10000 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): /IAQ/-A I
)ecific Lot Numbers (must match Alb): I-
��
Leua|�Reaoonsib|eOrnanbatona|Ent�y(must n�otch81): / i/A ���/��� ��c
-Legally Responsible Person (must match B2 & B3): C /Z
+�Title of Legally Responsible Person (must match B3b):
Name & Title ofSigned ifAuthorized Individual
Legally -Differs from
Phone Number:
5ignatu |k/ b|ePerson urAuthorized Individual
* VNPORTANTNOTE. This form m—u-stbesigned byoresponsible corporate officer that owns moperates the construction nctivity,
such coopresident, secretary, treasurer, orvice president, oromanager that isauthorized /naccordance with Part IV, Section B,