NCC222654_NOI Signed Certification_20220727

NCGO1 Notice of Intent (NOI) 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
DO NOT K0,41LTHIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
'?' C1gwR )'0t' ►,,-,,cT SE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.22]
Per NC G-rneralSaetute 1Z3-21S.6B (ij, cn),person who knowingly makes any false statement, representation, or
certi5.-rtion in any application, record, report, plan, or other document filed or required to be maintained under this
A ,icle a- a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars (S101").
aenatty of lav,, I cent f. , that (check all boxes to indicate your agreement):
El I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any cM.1 or criminal penalties incurred due to violations of this permit.
D The info=,ation su5rn;;.ed 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
ga;hermg the informa,icn.
1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Piano
i ✓ I` the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the %'CG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
ae-mR are met on the project at all times.
I✓ I he-eby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will con;tttute the permit requirements for the discharge(s) and is enforce.ible in the some manner as an
individual permit.
Name (mua match Al.), Poplar Forest Subdivision
S;*-cific Lot Numbers (must match Alb): Lots 1-74
PermRtee (muff match 81): Poplar Forest LLC
Legally Responsible Person (must match B2 & 83): Williarn N. Adkins
Title of Legally Responsible Person (must match 03b): ManaOor
Name E Title of Signed if Authorized Individual
Differs from Legally Responsible Pvr-,wr
Phone Number: [phone]
7/21 /22
Signature of legally Responsible Person or Authorized Individual Date
IMPORTANT NOTE: This form must be signed by u respurtslble carpurute ufficer that owns or operutes the construction activity,
such as a president, secretary, treasurer, or vice president or u ►rrunuger tltut Is auttiurliecl in accordance with Part IV, Sectlon B,
item (G) of the NCG010000 permit.
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