NCC221139_NOI Signed Certification_20220325

NCG01 Notice of Intent (NOI) Certification Form
Directions: -
Print this form, complete, scan and upload to the electronic NCI.
Then, mail the original form to the NC DEMLR 5tormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stomnwater Program
512 N. Salisbury Street, 6a Floor (Office 640C)
1612 Mall Service Cantor
Raleigh, NC 27699-1612
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 121221
Per NC Generol Statute 143 215.68 (l), any person who knowingly makes any false statement; representation, or
crrt#k+otlon in any oppikadon, record, air, Pam, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shag be pinky of a doss 2 misdemeanor whkh may include a fine not to
exceed ten thousand dollars 1$10,000j.
Un;71
aky of law, 1. certify that (ChetJk al boxes to indlate your agreement);
am the person responsible for the construction activities of this project, for satisfying the requirements of this
per t, and for any civil or criminal penalties incurred due to violations of this permit.
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
thering the information.
will abide by all conditions of the NCG010000 Gentral Permitand the approved Erosion and Sediment Control
F
If the approved Erosion and Sediment Control Plan is not compliant with Part it (Stormwater Pollution
Prevention Plan) of the NCGOIDWO General Perm, I will nonetheless ensure that ail conditions of Part II of the
permit are met on the project at ail times.
L4hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the disthargeisj and is enforceable in the same manner as an
individual permit.
S ��,T �o
Prokct Name (must match Ala): � ✓ A l % � `d'��1 L ("Ile
'tr
Ific Lot Numbers (must match Alb):
Permittee (must match ell: C / 'Ott '
sible Person must match 82 & 03): UJ U
i
Title of Lgally Responsible Person (mast match 83b): f c I
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number- ­5 3 —
Signature of Legally Responsible Person or Authorized Individual Date
• IMPORTANT NOT . This farm must be signed by a responsible corporate offker 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 8,
!tern (6) of the NCGOIWW Permit.