NCC230069_NOI Signed Certification_20230111

NCG01 Notice of Intent (NOI) Certification Forth
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form tothe NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6m 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 122,221
Per NC General Statute 143-215.6E (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 ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
EIrl am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
based an my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
C�J I wi{I abide by all conditions of the NCGU10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): neAD 4upe- AI C.e—
Specific Lot Numbers (must match Alb
Permittee (must match Bl): MA) H�apL PI(We— L&
Legally Responsible Person (must match B2 & B3):
Title of Legally Responsible Person (must match B3b): }�
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: zliP--(pu--$n
Signature of LeAY Re"sible Perso6 or Authorized Individual
Date
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* IMPORTANT NOTE. This farm 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 Part IV, Section 6,
item (6) of the NCG010000 permit.