NCC217050_NOI Signed Certification_20211220

1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS SEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED ri'iiITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122,22]
Per PVC General Stotute 143-215.6B (i), any person who knowingly mokes any false statement, regresentption, or
certification in airy application, record, report, plan, or other document filed or required to be malntainLod under this
Article or u rtile rrrrplementino this Article ... shall be guilty of a Closs 2 rnisdemeanor which mQy include a fine no t to
exceed tar+ thousand dollars ($10,000),
Under penalty of law, I certify that (check all boxes to indicate your agreement).
❑d i am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and far any civil or criminal penalties incurred due to violations of this permit.
FVJ The information submitted in this NO1 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 1 will abide by all conditions of the NCGO10O00 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part II (5tormwater Pollution
Prevention Plan) of the NCG010000 General Permit. I will nonetheless ensure that all conditions of Part 11 of the
. permit are met on the project at all times.
[]J 1 hereby request coverage under the NCG010000 General Permit and understand that coverage underthis
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 A1o): Cherr ours Barrier Wall Construction
0 Specific Lot Numbers ( rust match Alb):
Perrnittee (must match 81}: The Chemours Company -
Legally Responsible Person (mustmatch V & B3): Sebastian Bahr
Title of Legally Responsible Person (must match 63b): Project Manager
Marne & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 609-2 - 53