NCC230976_NOI Signed Certification_20230405

NCGO1 Notice of Intent (NOI) Cert'ficat'on Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form to the N[ DEK0LR5torrnxvater Program (with $1UO check/f paying bv check)at:
Division of Energy, Mineral & Land Resources StnrnnvvaterProgram
512 N. Salisbury Street, 61, Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC27699-1612
DD NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
certification/n any application, record, report,plan, or other docunnentfiledorrequired to be nno/nbo/ned 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, | certify that(check all boxes to indicate your a8reennent):
[�| | am the person responsible for the construction activities ofthis project, for satisfying the requirements ofthis
! permit, and for any civil or criminal penalties incurred due to violations of this permit.
[� The information submitted in this NO| is,to the best ofmy knowledge and belief,true, accurate, and complete
| based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
��
c� | will abide by all conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
| Plan.
/ Fv] If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
| Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions of Part || ofthe
!
� permit are met on the project aA all times.
Ft/� | hereby request coverage under the NCG010000 General Permit and understand that coverage under this
/ permit will constitute the permit requirements for the discharQeb) and is enforceable in the same manner asan
/ ` '
� individual permit.
� SOUTHEASTERN CONCRETE
Project
| Specific
�
/ jAMES MUSSELWHITE
� Legally b| j/\MES MUSSELWHITE
|
� Title of Legally b| MEMBER/OWNER
Name &Title of Signed if Authorized Individual
Differs from U
| Phone b 910-671-1964
|
|
Signature or c�nny nesponsm/e peru�n orxutAon�eU |n�/mUua| Dote
- 8NPORTANTN0TE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as o president secretary, treasurer, or vice president, or manager that is authorized/n occon/000e with Part/K Section B'
Item(6)oƒthe N[GOl000Opermit.