NCC224205_NOI Signed Certification_20221229

NCGO1 Notice of Intent (N01) Certification Form
Directions*
Print this farm, complete, scan and upload to the electronic NOL
Thin, 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 Progrann
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 Genera! Statute 143-215.6B (i)f and person who knowin9 ly makes anyfalse statement, representation, or
certrficatian in any applieartion, retard, repvrt, p /a n., or other d o cum e n t file d or required to b e malntained under phis
Article or a rule implementing this Article ... shall he guilty of a Class 2 misdemeanor which rrrcry include afine not to
exceed tin thousand dollars ($10,000).
Under penalty of law., I certify that (check all boxes to indicate your agreement:
1 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 violatians of this permit.
The information submitted in this Nab is, to the crest 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 Control
Plan,
if the approved Erosion and Sediment Control Plan is not compliant with Part I! (Stormwater Pollution
Prevention Plan) of the NCG010000 General Per I will nonetheless ensure that all conditions of Past II of the
permit are met an the project at al times,
a I hereby request coverage under the N CG010000 Genera I Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enfQrceabie in the same manner as an
individual permit.
Project Name (must matchA.1d): Carolina Land & Lakes RC&D Education Warehouse.
Specific Lot Numbers (must match Alb):
Permittee (must match BI): Carolina Land & Lakes RC&D
Legally Responsible Person (must match BZ & 83) Melissa Patton
Title of Legally Responsible Person (must match B30- Executive DireGtor
name & Tit le of Signed if Auth o rize d I nd ivid ua I
differs from Legally Responsible Person:
Phone dumber: 828-244.8722
Signature of Legally #�'es�avnsible Person or Authorized Individual
'Ifte - .
Hate
IMPORTAAff NOTE; Thisform must be signed by a responsible cor orate officer that owns or operates the construction activity,
such as a president,,# treasurer., or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item the NCGO10000 permit.