NCC222769_NOI Signed Certification_20220803

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Print this form, complete, scan and upload to the electronic NOI.
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
FORIPA OR
PAYMENT Tfl YOUR APPLICATION
HAS BEEN
ACCEPTED
D m E'
_O., t..S BE C_. __ iT`. AN>I�AL ,, �..>.�s t.
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 air, the person responsible for the construction activities of this project, for satisfying the requirements of ti~is
permit, 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
gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Contrc€
Plan.
✓� If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the N CGt.1Ci000 General Permit, I will nonetheless ensure that all conditions of Part II of
permit are met on the project at all times.
✓� 1 hereby request coverage under the N GO10000 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
individual permit.
Project Name (must match Ala): Mayo -Person 500kV Line: Lattice Tower Replacement
Specific Lot Numbers (must match Alb): Dud<C PRE Re_ss U ?i L ,Ty EASF—MEN i
Permittee (must match BV: Duke Energy Progress, LLC
Legally Responsible Person (must match B2 & B3): Nuwan Wijesuriya
Title of Legally Responsible Person (must match B3b): Lead Transmission Permitting Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-546-2090
Signature of Legally sponsibleell
rson or Authorized Individual
T WPOPTANT 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 Port IV, Section B,
Item (6) of the NCG010000 permit.