NCC230576_NOI Signed Certification_20230314

NCG01 Notice of Intent (NOi) Certification Form
Directions -
Print this form, complete, scan and uoioad 10 the electronic N(,
Then, mall the original form to the NC DIVI R Stormwater Program (with 5100 check if paying bycheckl at
Division of f neigy, Mineral 11 Land Resource% Stormwater Vropran
1)12 N Salisbury Street. 611, floor ((lilu a 640K)
1612 Mail Service Cenler
Raleigh, NC 27699� 1612
DO N01 MAIL I HIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCFPTED AS COMPILE"!
THE FORM YOU MAIL MUST DE COMPIETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) i40 CFA ]22.221
Per NC Genera! Statute 14.3-215.6FI lit, any person who knowingly makes any false statement, representation, al.
certllrcation In any application, record, report, plan, or other document Jiled or required to be maintained under this
Article or a rule implementing this Article . , . shall be guilty of a Class 2 misdenreonor wl+rc h +nay include a fine not to
e.krred Ira rhomond dollots (S1 U UU(11
Under penally of law. I certify that (check all boxes to Indicate your agreement)
0 I am the person responsible for the 1 onstruction activdil.s of lluti protect, for satisfying thr tequi+ementt of this
permit, and for any civil or criminal Imnalfles Incurred due to vlolallons of this permit
© The information submitted in this NO] is, to till. best of my knowledge and belief, true, accurate, and complete
based on my Inquiry of the person or persons wllo manage the system, or those persons directly responsible for
gathering the information.
Q 1 will abide by all conditions of the NC6010000 General Permit; and the approved Lrosion and Sediment Control
Plan.
© If the approved Lrosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the Pnelill 1,1:11viij,I will nonrthr'Ietis ensure that all conditions of Part if of the
permit are met on the project It ell t}mes.
© I hereby request coverage under the NC111010000 GenerALPl't[11it and undr+�.iand that coverage under this
permit will constitute the permit requlrementtl for the discharge(s) and Is enforceable in the same manner a% an
individual permit.
I'rolry I Wme (rrimf Irmf(h Ala.):_Ctanimrtnli
n
Spl.riNc Lot Numbers must lmorrh Al h)
I'1'111111lev (1llflSf Illarrh BT): vflll.i( ill /1,IrT(:.
I r .ill he- ,llnrr,1b11' 1'ersorl (rrr+r..( match 62 & fi.t) R Todd Wilharris
Title of I e'f;aliy Respon',rhle I'er',11n must match If lb). UIFf1C101
Nanrr k I Ile of Signed if Authorved Individual
Iliffrrs flejnl I eNally Rrtilnlmlhle I'er�ion; —
Phone Nunlhe.'r [phone]
2v2'S--
Slgnature *egafly Itcsoonsibir Person or Authorised Individual Daly
1MPORTANf NO1E: nin /arm rni,+f be votird by a ►r+ponslble corporate- oJfirer that owns or operorm the, construction artivlty
such a+ a lrrrsldrnr, %rcrrfary, rrrosurrr; or vier prrsedrnt, nr a n1anogrl filar A erufho►Ued In accordanrr with Port IV, Section R,
Ifrn1 (b) of flee N[ (.OIOOW pr►nllr.