NCC220941_NOI Signed Certification_20220303

NCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload tmthe electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StormvvaterProgram
512N. Salisbury Street, 6~Floor (Office 640K)
16IZMail Service Center
Raleigh, N[27699-l612
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 NCGeneral StatuteI43-22�6B (i),ony person who knowingly makes onyfalsestatement, representation, or
certification /nany application, record, report, plan, urother documentfiledu/required tobemaintained 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 /$1(l00D/.
[�| 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 |nthis NO|is, tothe best nfmyknowledge 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.
ED | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
[71 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions ofPart Uofthe
permit are met onthe project atall times.
[�| | 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 A2o):George Young
b1-24-10AND 12-35
-Permittee (must match Bl): -Specific Lot Numbers George Young /Matt@mVHomes
Legally Responsible Person (must match 82&B3): George Young
Title of Legally Responsible Person (must match B3b): Vice President
ME Individual Date
* 0MPORTANTNOTE: corporate officer that owns oroperates the construction activity,
such osopresident, secretarVeasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6)u/the NCGD 0000pcnnit.