NCC216561_NOI Signed Certification_20211123

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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, 61h 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 122.22]
Per NC General Statute 143-215.6B (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):
Ul"' 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 N01 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.
ILK l will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
�Plan.
L0/ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
10 1 hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements forthe discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): Line 96 Parmele - Everetts Transmission Line Rebuild Phase 1
Specific Lot Numbers {must match Alb): Multiple -see attached sheet
Virginia Electric & Power Company dibla
Legally Responsible Organizational Entity (must match B1): Dominion Energy North Carolina
Legally Responsible Person (must match B2 & B3): Mark Allen
Title of Legally Responsible Person (must match 133b): Director, ET Project Development & Execution
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 804-257-4711
ignature of Legally Responsible Person or Authorized Individual
9 f 21
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 NCGO10000 permit.

Attachment 1
Line 96 Parmele -- Everetts Transmission Line Rebuild — Phase 1
Specific Lot Numbers (must match Alb)
Parcel 1D 'Numbers .
24729
0700277
0700801
11380
0700891
0701694
00477
0700070
0701695
29669
0703095
0701660
0701692
0700008
0703349
12823
0701917
0700728
0700596
0701381
0702930
09260
0702341
0701564
070OS95
0702111
0700993
23351
0700585
0703089
070176S
0701001
0702881
0703176
0701618
0702882
0702896
0700897
0703190
0702897
0700379
0702212
0702898
0702165
0702321
0703000
0701899
0702218
0703001
0701816
0700639
0701709
0701815
0700461