NCC221052_NOI Signed Certification_20220315

Directions/
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources 8tormvxaterProgram
5l2N.Salisbury Street, 6mFloor (Office 64OK)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NCGeneral Statute 143-215,6B (i), any person who knowingly makes anyfalse statement, representation, or
certification /nany application, record, report, plan, or other documentfiled or required to be maintained under this
Article orarule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($18O00).
Under penalty oflaw, |certdy that (check all boxes to indicate your agreenment):
E� 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.
k� The information 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
gathering the information.
r�
iwill abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
_/
h� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart 1|ofthe
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.
ectName (must match A1oA: rh 0,thov-rA FarK- NC(-0) ph(KS-e_ � F,LUfS /4(e-/5
Specific Lot Numbers (must match Alb): )4 & -I j:_�
Legally Responsible Person (must match B2 & B3):
Title of Legally Responsible Person (must match B3b): V CC)C)
Name & Title ofSigned ifAuthorized individual
Differs from Legallv Responsible Person:
Phone Number: 4 7
Signature of Lega*Responsible Person or Authorized Individual
3AIZZ
Date
*�����TE.- This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such osopresident, seoetoq\tneosurer,orvicepnesi/ nt,orom000gerthot isauthorized /naccordance with Part IV, Section B,