NCC216146_NOI Signed Certification_20211115

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 5tormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, fiw Floor (Office 540K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MALE THiS FORM OR PAYMENT UNTIE YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FARM YO I MML MUST BE COMP1.E`lI WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 7.22.22]
Per NC General Statute 143-2I5.0 (i), any person who knowingly makes any false statement, representation, or
certification in any application, retard, 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).
ig I am the person responsible for the construction activities of this project, for satisfying the requirements of this
f permit, and for any civil or criminal penalties incurred due to viofations of this permit.
1J 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.
If the approved Erosion and Sediment Control Pian 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
f permit are met on the project at al! times.
Q' I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala):Q
Specific Lot Numbers (must match Alb): f R
Responsible Organizational Entity (must match 81):
Legally Responsible Person (must match B2 & 63):�
Title of Legally Responsible Person (must match 03b):
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone !Number
Signature of Le;ka,
?-'5^ GI'I - 2 q 1
ly Responsible Berson or Authorized Individual
Date
IMPORTANT NOTE: T►ris 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 S,
Item (5) of the NCGO1000o permit.