NCC221929_NOI Signed Certification_20220523

NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6° Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
UO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BF COMM FTFf) WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) i40 CFR 122.721
Per NC General Statute 143-215,6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report plan, or other document filed or required to be maintained 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 ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
�✓ I am the person responsible for the construction acbvitics of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties imcurred due to violations of this permit.
�✓ The information submitted in this N01 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.
Q I will abide by all conditions of the NCGU10U00 General Permit and the approved Erosion and Sediment Control
Plan.
[]✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, l will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
❑� 1 hereby request coverage under the KGO.1.0 00 General Permit and understand that coverage under this
permit will constitute the permit requirements for the dischargei;s) and is enforceable in the same manner as an
individual permit_
Project Name (must match Ala): Concrete Supply Co., L.L.C. Site Plan
specific Lot Numbers {must match AIM: NIA
Permittee (must match 81): Concrete Supply Co., L.L.C.
Legally Responsible Person (must match 82 & 83). Henry Batten
Title of Legally Responsible Person (must match 83b): President
Name & Title of Signed if Authorized Individual NIA
Differs from Legally Responsible Person:
Phone Number: [phone]
a
Signature of Legally
�U/1 40 2
Person or Authorized Individual Date
IMPORTANT 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 5,
Item (6) of the NCGO10000 permit.