NCC217021_NOI Signed Certification_20211220

NCGO1 Notice of intent (N4i) Certification Form
Directions:
Print this form, complete, scar and u0oad to the ekKV0r1k Plick
TM�►, mall the original form to the NC DEMLR Storrnwater ProgT>m (wrtfi 5100 dsexk i by
Dh6slon of Energy, Mineral & Land Resouraa %WWWAK
512 N. Salisbury Street, 6* Floor (Off'ie 64010
1612 Mail Service C.erner
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTiL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 (1), arry Person who knowingfy makes any false staterr>'E'"t• represent
or certification in any application, record, report, pion, or other document filed ar required to be mar>allimed
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misde"whv ar wf MW
Include a fine not to exceed ten thousand dollars ($10,000).
Und,,.err penalty of law, I certify that (check all boxes to indicate your agreement):
© 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 violatiorts of t
permit.
MW
The information submitted in this NO] is, to the best of rrry knowledge and belief, true' accurate,
complete based on my inquiry of the person or persons who manage the system, or those P`ef�
directly responsible for gathering the information.
I will abide 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 «`a"T'watef Pdl+mon
Prevention Plan) of the NCGO1000 _General Permit I will nonetheless ensure ---- _ condrtioxts Of
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage ur:der
this permit will constitute the permit requirements forthe discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: r I n 1 !�
Legally Responsible Organizatio al Entity: 11 -� Y`Q k4cm-cS k n C
Legally Responsible Person: �"�
Title of Legally Responsible Person: i
Date:
*Signature:
�
*Print Name and Title of Agned if Authorized
individual Differs from Permittee: rA
Phone Number: q � Cl — f }� ' 1 C1 11(} cc
* IMPORTANT NOTE: This farm 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 N, Section B, item (6) of the NCGOIOOW permit.
For more information on signatory requirements, see Part IV, Section B, item (6) of the NCG01000O permit