NCC223245_NOI Signed Certification_20220916

F
NCGO1 Notice of Intent (N01) Certification Form
Directi0ons,
Print this farm, complete, scan and upload to the electronic N01.
Then, maid the original form to the NC DEMLR Stormwater Program (W 1 $ C ec if paying by checks at:
Division of Energy, Kneral & Land Resources Stormwater Program
512 N. Salisbury Street, 5& Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
QD IVOT MAIL THIS FQRM qR PAYMENT UNTIL YOUR A P P LI CATIO N HAS BEEN ACCE PTE D AS CO M PLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NET DIGITAL) [40 CFR 122.22]
Per NC GeneralStatute 143-215.68 (i),. any person who knowingiy makes arryftrlse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maini-arned under this
Article or a rule implementing this Article ... sharl b e guilty of cr Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($i 0, aDo).
Under �alty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construct -ion activities f this ro•e t for satisfying
� � �the requirements of this
permit, and for any civil or criminal l penalties incurred due to violations of this errs it.
The information submitted in this NCI is, to the best of my knowledge and belief, true, accurate, and compete
based an my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information,
Ia. I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment control
Phan,
,L�r If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Perm�t, ! wilt nonetheless ensure that all conditions of Part !i of the
permit are met on the project at all times.
I hereby request coverage under the NCG410000
eneral 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 math A1a):
Specific dot Numbers (must mach Alb):
Feria (must match 1:
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Legally Responsible Person (must match BZ 8c B3): -�,�
Title of Legally Responsible Person (must march Bab):
i
Name &Title of Signed if Authorized Individual �
Differs from Legally Responsible Person:
phone Number; 71 1
Signat
'of Legally Responsible Person or Authorized irtdividua!
M
Dot
z
IMPORTANT OTE: Thisform r. t be signed by a responsible corporate officer that owns or o erates the ciF
c
such a a President, ecr hor , treasurer, or vice presi e t, or a manager that I. authorized i accordance with Per
} V, Se c tio n B,
Item (6) of the NCGO10000 permit.