NCC230638_NOI Signed Certification_20230313

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, 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 Program
512 N. Salisbury Street, 6,b Floor (Office. 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN. ACCEPTED AS COMPLETE.
THE FORM YOU�MAIL R O 't BE COMPLETEDi WITH-AN'ORIGINAL SIGNATURE (N©T DIGITAL) [40'CFR 122.22]
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):
❑✓ 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.
Q The information submitted in this N01 is, to the best 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 responsiblefor
gathering the information.
0 l will abide by all conditions of the NCGO10000 General Permit and the approved. Erasion and Sediment. Control
Plan.
0 If the approved Erosion and Sediment Control Flan is. not compliant with Part Il (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of Part Il of the
permit are. met on the project at all times.
0 1 Hereby request coverage under the NCGO10000 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): Piedmont Natural Gas Dan Valley HDD Road Relocation Project
Specific Lot Numbers (must match Alb): NIA
Permittee (must match Bl):.Piedmont Natural Gas Company, Inc
Legally Responsible Person (must match B2 &.83): Daniel Deese
Title. of Legally Responsible Person (must snatch B3b): Project Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person`
�Qf�
Phone Number: 704 �S-4;5-s-l'D
Signature .of egally Responsible Person or Authorized Individual
'9 G
D e
* IMPORTANT NOTE: This form 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 0,
Item (6) of the NCGO10000 permit.