NCC215961_NOI Signed Certification_20211027

NCGOI Notice of Intent(NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronicN0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division ofEnergy, Mineral & Land Resources 3znrnnwaterProgram
512N.Salisbury Street, 6*Floor (Office 54OK)
161IMail Service Center
Raleigh, NC2769Q'1G12
Per NCGeneral Statute 243-215.6B(i),any person who knowingly makes mnyfabstatement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article orurule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Uod oltyoflavx icertify that (check m#boxes tmindicate your agneenmant):
7|amthe person responsible for the construction activities ofthis project, for satisfying the requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
E/ The information submitted in this NU 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.
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�� | will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
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E� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe KGO10000 General Permit | will nonetheless ensure that all conditions ofPart ||ofthe
permit are met onthe projectatall times.
G� | hereby request 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
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Name of Project (must match Ala): (jZ61W 4%JD!e-:-
Specific Lot Numbers (must match Alb): Zo7 �f
Legally Responsible Organizational Entity (must match Bl).—?*t �4rT Ctl (7% )�J Lt-,-- --
»onsib|ePerson (must match 82& '~~7 /
Title ofLegally Responsible Person (must match B3b):
Name & Title ufSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Signaturi-of Legally
Person orAuthorized Individual
*IMPORTANTNOTE. This form must be signed byuresponsible corporate officer that owns or operates the construction activity,
such asopresident, secreta% treasurer, or vice president, oromanager that is authorized in accordance with Part IV, Section B,
Item (6)ufthe NCGO10000pennit.