NCC222642_NOI Signed Certification_20220725

NCGO1 Notice of Intent (N01) 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, 6th 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 122.22]
Per NC General Statute 143-1,1211115, 51B
certification in any application, reco
(i), any person who knowingly makes any false statement, representation, or
rd, report , plan,, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article ... sha
exceed ten thousand dollars ($10,000).
11 be gu
illy of a Class 2 misdemeanor which may include a fine not to
Under Denaltv Of Ii w I Ceril{V that [f1P[k aill hnwpc. to inefirnto n"r norommantl•
[1� I am the person responsible for the construction activities of this project, for satisfying
ermit, and for any civil or criminal penalties incurred due to violations of this permit.
0
the requirements of this
ne mtormation submitted in this NOI is, to the best of mv knowledge and belief, true, accurate, and complete
7ath
ed on my inquiry of the person or persons
ering the information'.
Plan
abide by a
Is
who manage the system, or those persons directly responsible for
II conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit. I will nonetheless ensure that;fll conditions of Part II of the
permit are met on the project at all 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 I in the same manner as an
individual permit.
Project Name (must match Ala):
SsoO w.\g�o�e.
Specific Lot Numbers (must match Alb): 500
Permittee (must match 131):
legally Responsible Person (must match B2 & B3):
An�
Title of Legally Responsible Person (must match B3b): M(�
Name & Title of Signed if Authorized Individual (�
Differs from Legally Responsible Person: \-'r\4\3�c, p\r.er S e o c\
Phone Number: 7 04 4AW'791-`71S
Awl
Signature of Legally Responsible Person or Authorized Individual
( �4- S S-q4 \)
'71 / / ) ?
Date
IMPORTANTNOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,,
such os o president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 permit.