NCC216259_NOI Signed Certification_20211110

NCG01 Notice of intent (NO11) Certification Form
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLRStormwater 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
Per NC General Statute 143-215.69 (i), any person who knowingly makes anyfalse 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 f$10,000).
Under p"alty of law, I certify that (check all boxes to Indicate your agreement).
.121", am the person responsible for the construction activities of this project, for satisfying the requirements of this
/Pe rrnit, and for any civil or criminal penalties incurred due to violations of this permit.
2 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
thering the information.
L/i �Iwill abide by all conditions of the NCGQ1 0000 Generai Permit and the approved Erosion and Sediment Control
/ [an.
-1, the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will, nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
I hereby request coverage under the NCGOIGOOO 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):
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity (must match6l):
Legally Responsible Person (must match 82 & 83):
Title of Legally Responsible Person (must match 83b):
Name & Title of Signed if Authorized individual
Differs from Legally Responsible Person:
Phone Number: 4---7 tq - 6601-3 ' 5t 3r
IMPORTANTIVOTE. 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, Sectior? B,
Item (6) of the NCG010000 permit,