NCC230245_NOI Signed Certification_20230127

NCG01 Notice of Intent (1401) Certification Form
Directions:
Print this form, complete, scan and upload to the electrcnic NOI.
Then, mail the original form to the NC Cl:-MLR Stormwater Program (with $1C 0 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwate- Program
512 N. Salisbury Street, 6,� Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYME14T UNTIL YOUR APPLICATION HA5 BEt N ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE i NOT DIGITAL) 140 CFR 122.221
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false s � itement, representation, or
certification in any application, record, report, plan, or other document filed or requ, red to be maintained under this
Article or a rule implementing this Article . . . shall be guilty of a Class 2 misdemeanci' 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 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.
L�J The information submitted in this NOI is, to the best of my knowledge and b lief, true, accurate, and complete
based on my inquiry of the person or-,ersons who manage the system, or L-TUse persons directly responsible for
gathering the information.
lJ I will abide by all conditions of the NC,3010000 General Permit and the approved Erosion and Sediment Control
Plan.
FM If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG01DD00 General Permit, I will nonetheless ensue 2 OWL all wndidUris Uf Pdrt II of the
permit are met on the project at all times.
dI 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 e4orceable in the same manner as an
individual permit.
Project Name (must match Ala):
Specific Lot Numbers (must match Alb):
Permittee (must match B1): V Gr M �"f 'o f d l y �s . L I- C-
C S �e
Legally Responsible Person (must match B2 & B3):
rn
Title of Legally Responsible Person (must match 83b): If t' I h a
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:: r� 1 _
Phone Number: / r 0 6 ! ! j
Signature of legally R
on or Authorized Individual
I -)S-)3
Date
* IMPORTANT NOTE: This form must be signed bil a responsible corporate officer that owns or operates the construction activity,
such as a presidenr, secretary, treasurer, or vice �residenr, or a manager that is authorized in accordance wirh Pori IV, section 8,
Item (5) of the NCG010000 permit.