NCC220060_NOI Signed Certification_20220106

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NCG01
Notice of Intent (NOI) Certification!Forrn
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then-, mail the original form to the NC DEMLR Stormwater Program (with $100 check lfpaying by check) at.,
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6u Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MA IIL THIS FORM OFF PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE,
THE Ff" "J MAW MUST BE Ci?1M pLETED 1AliTH AN QRIt31NAL SIGNATURE (I�OT €i1GiI'A!<..) 140 CFR M.221
Per NC General Statute 143-215.6E (i), any person who knowingly makes an
certification in any application, record, report, plan, or other document filed or required tobe maintainedtionunder this
Article or a rule implementing this Article ... shall be guilty of a Class 2 is which may include a fine not to
exceed ten thousand dollars ($1QOOD}.
!Und71am
nalty of law, I certify that (check all boxes to indicate your agreement):
the person responsible for the cons
truion/is Prect, for satis
permit, and for any civil or criminal penalt es incurredJdue to ties v olations of this permitg the requirements of this
2' The in€ormation 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
thering the information,
will abide by all condition of the NCG010000 General
Plan. Permit and the approved Erosion and Sediment Control
M If the approved Erosion and Sediment Control Plan
' '
neral PermitI will nonetheless s not compliant 3ensu e that all conditions th Part 11 (Stormw ter liof'Part If of the
Prevention Plan) of the NCG010000 Ge
rmit are met on the project at all times.
I hereby request coverage under the NCG010000 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.
Name of Project. (must match Ala):
acific Lot Numbers (must match
j Title of
%— q
vfsaF,izanonal t:ntrty (must match B2):
Person (must match B2 & B3): �} F
sible Person (must match 93b
Name & Title of Signed if Authorized Individual v
Differs from Legally Responsible Person:
Phone Number: _ 3 _ 60 d — 7�2y �-
Sign ture gall spons- Pers rAuthorized Individual
Da e
* ;!MPORTANT 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 IVCGO10000 permit,