NCC223697_NOI Signed Certification_20221031

NCGO1 Notice of Intent (Noll) Certification Form
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division nfEnergy, Mineral & Land Resources StunnmmterProgram
512N.Salisbury Street, 6`^Floor (Office 64OK)
1612Mail Service Center
Raleigh, NC27699-16l2
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 C1FR 122.22]
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, mrother documentfiled or required to be maintained under this
Article nrorule implementing this Article ... shall beguilty qfoClass 2misdemeanor which may include ofine not /u
exceed ten thousand dollars /$2(IDDD/.
Under penalty oflaw, | certify that (check all boxes tmindicate your agreememt):
Fv_J I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[v� The information submitted in this NO| is, 1othe best ofmyknowledge 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.
| will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
[�l If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart Uofthe
permit are met onthe project a1all times.
| hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the dischargeb\and benforceable inthe same manner aoan
individual permit.
Project Name (must match Ala): Transylvania County EMS Base
-Specific Lot Numbers (must match Alb):
Permittee (must match Bl): Transylvania County
Jaime Laughter
Responsible -Legally Responsible Person (must match B2 & B3): -Title of Legally County Manager
Name /& Title ofSigned ifAuthorized Individual
-Differs from /Responsible
re of Legally Respon-sible Person or Authorized Individual
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,