NCC216610_NOI Signed Certification_20211206

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 DEMLA Stormwater Program (with 5100 check if payrng by cfeut) at.
Or i wn of Energy, Mineral r>G land Resources Stormwater Program
S12 N Salisbury Street, 60, Floor (Office 610y)
1612 Marl Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE
THE FCWJA YOU MAIL MUST BE COMPLETED WTTH AN ORIGINAL SIGNATURE (NOT D1GRAL) 140 CFR 122.22)
Per NC General Statute 143-215.0 (i), any person who knowrngly 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 1 misdemeanor which may include a fine not to
exceed ten thousand dollars (S10,0100).
Under penaky of law, I certify that (check all boxes to indicate your agreement)-
1 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_
I will abode by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan
[ 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.
I 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
individual permit.
Project Name (must match Ala): f(2,5c4*- 0-,,r- 6, Z 0 2-
Specific Lot Numbers (must match Alb): 15 , Z°, ZZ1
Permittee (must match B1):
Legally Responsible Person (must match B2 & 83): < ,)
Title of Legally Responsible Person (must match B3b): Q A,--,-tizlJ
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 7 % O Z416 101-3
Sig of Legally Responsible P5;s6n or Authorized Individual
I j LS Z
D to
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.