NCC230856_NOI Signed Certification_20230328

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
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 Floor (.Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
D® YOU MAIL MUST BE cNOT MAIL THIS F OR PAYMENT
OMPLE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [4Oo RP
THE FORM122 221
u�
Per NC Genera! Statute 143-215.6E (i), any person who knowingly makes any false statement, represents ion, 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).
L (C'hec..M1 a s to indllicate.. 1710W;
Under penalty of lave, I certify that _--: L:xe,
i i-this project, for satisfying the requirements o'! this
i am the person responsible for the construction t;activ,-s of
permit, and for any civil or criminal penalties incurred due to violations of this perrnit.
The information submitted in this N71 is, to the best of my knowledge and belie€, true, accurate, and corn plete
based on my Inquiry of the person or persons who rnanage the systerri, or those persons directly respansibke for
gathering the information.
r` F -d-r.Ocini� ::�,:� �edimenr Control
il' ;de' -i! (-c ,ditie :s of the NCGD1o04D-General Permit and--''ro,_
Ell i aDI �y - , r
Plan,
If the approved [rosion and Sediment Control Plan is not complidn"_ V it Pa'i II (SIOrm\A; eI- Pol uilol-
ED:Prevention Plan) of the NC13010000 General Permit, I f.��iil nonetIhel=ss ensure t^.tall conditions of Part II cf _he
p,ermi'L are met on tha project at ail limes.
El 11 „erebv -_cues`_ coverage under t-Ine NCGO10000Genera Permit and L11'ierSLa1lu c b=rage ui
rinit Will colrIsdtu�e the permit requirements for the discharge(s) and Is enforceable In the same manner a5 an
p�ci
iriui���..�ua
J:..idu 1
i Per iiilt.
Project Name (must match 41a): 1111LI
Specific Lot Numbers (must match Alb): a(A�-
Permittee (must match 81): D rt0m findexs thTr-
Legally Responsible Person (must match 82 & 83): 2Sh2 GYOVBS_ ---
Title of Legally Responsible Person (must match 83b): DOV �S)Oh pY�SIdP.
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: �-
c _�1 R 4
X
Number; ��10 85-4.. -
Si nature of Legally esponsible Person or Authorized Individual
g
11.31a3
Date
IV, PORTANTNOTE: This form must be signed by o responsible corporate officer thot owns or operates the construction activity,
such os o president, secretary, treasurer, or vice president, or o monoger that is authorized in occordonce with Port IV, section 8,
Item (6) of the NC-G010000 per -nit.