NCC230892_NOI Signed Certification_20230330

NCG01 Notice of Intent (N0I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, maiJ the original form to the NC DEMLR 5tormwater Program (with SIDO check if Poyfpg by check) at:
Division of Energy, Mineral & Land Resources Starmater Program
512 N, Salisbury Street, 6th Flaor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED A5 COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN 0RIGINAL SIGNATURE (NOS' DIGSTAL) [40 Cr-R 122,221
Per NC GerneralStotute 143-215.SB (i), any person who knowingly makes anyfalse stotemenl, representation, or
certification in arny application, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule Implementing this Article ... shall be guilty of o Class 2 mfsdemeonor which may include a fine not to
exceed tern thousand dollars �$I Q,0W)r
Under penalty of law, I certify that (check all bones to indicate your agreement);
I am the person responsible for the ronstruction activities of this project, for satisfying the requirements of this
perm It and for any civil or Criminal penalties Incurred due to vlolations of t✓1is permit.
d The information submitted in this NCI 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 systern, or those persons directly responsible for
gathe ring the information_
✓ I will abide by all conditions of the NCGG10000 General Permit and the approved Erosion and Sediment Control
Plan_
If the approved Erosion and Sediment Control Plan is nat compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that atl conditions of Part II of the
permit are met on the p roject at al l times.
❑v I hereby request coverage under the NCG010000 General Perrnit and understand that coverage under this
perm Wjll constitute the permit requirements for the discharge(s) and is enforceable in the same rnanner as an
individual permit,
Project Name (must match Ala): Mooresville Auto Paris
Specific Lot Numbers (must match Alb): 1
Permittee(must match 81),Llo dco,LL
Legally Responsible Person (must match 62 & 83); Bern Lloyd
Title of Legally Responsible Person (must match 83b): PNndpaI
Name & Title of Signed if Authorized Ind ividuaI
Differs from Legally Responsible Person:
Phone Number: 14-282-0123
1
Signature ofVega] ly Responsible Person or Authorized Individual
date
" IMPORTANT NOTE: T{us form must be sfgned by a responsible corpomte officer that awns or operates the Construction activity.
such as a president, secretary, treasurer, or vice Presiders; or a manager that is authorized irp accordOnce with Part IV, Sector+ 8,
Item (6J of the NC601 OEM parrait,