NCC222142_NOI Signed Certification_20220623

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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
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 122o22]
Per NC Genera! Sta t u te 143.2 15.613 (1), any person who knowingly makes any false statement, rep resentarr'on, or
certification rn any ppprrcQtian, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing tars Article ... shQ�l be gui.1
lty of a Class Z misdemeanor which may include a tine not �o
exceed ten thousond do llars ($1 0.� 000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Dam the person responsible for the construction activities of thisproject, for satisf in the re ui►ements of this
satisfying q
permit, and for any civil or crirY,inal penalties incurred due to violations of this permit.
�he information submitted in this N01 is, to the best of m knowledee iyand beJ ef, truc, accurate, and Gornplete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
athering the information,
will abide by all conditions of the NCGD14000 General Permit and the approved Erosion and Sediment Control
12 M...;
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Preve ntioii Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are �r�et on the project at all times.
i hereby request coverage under the NCGOlO00a 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 Ala): �G�-J�'� � r ce,
Specific Lot Numbers (must rnatrh Alb).4 _5 � — I I I
Permittee (must match Bl):
ke, r rroo_ I - ee'P 9L L C
- '_�Cc L ( ror C
legally Responsible Person (mu.5t match B2 & 83):
6�"V 1 COA
y_r
Title of Legally Responsible Person (must match B3b).4 � � ►` e,�
Name & Title of Signed if Authorised Individual
Differs from Legally Responsible Person:
Phone Nu
e--
Signifure of Legally Re
r
onsible Person or Authorized Individual
_-_�trj C-repoff
G /2/z ?..,-
Date
IMPQRTANTNOTE: This form must be signed by a responsible corporate officer that owns or operates the construction octrvity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part !V, Section B,
Item (6) of the NCG010000 permit.