NCC231075_NOI Signed Certification_20230418

NCGO1 Notice of intent (NOD) Certification Fira
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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't Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO 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 Genera!Statute 143-21 5.6B (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 (checkboxes to agreement):
I h ei- penalty of law, certify that a € - 3C f=� indicate yourc-
c_
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.
Ed The information submitted in. this NOI 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 responsible for-
gathering the information.
-� - and Sediment '��;_:...,�
will abide by all conditions of the NCG010000 General Permit and the approved Erosion m t Control
of
Plan.
Plan compliant If the approved Erosion and Sediment ControlPI n is not C_'."YI�liant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will noneth le<S ensure that all conditions of Part II of the
permit are rnet on the project al: all times.
J r�i-the-h and understand that coverage under
hereby request coverage under NCG010000 General Permitthis
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): ----rCiayo1 I a -
Specific Lot Numbers (must match Alb): a
81):DY�,OIMI find elS
Permittee (must iiiatcih Leslie —
Groves
Legally Responsible Person (must match 82 & 83): - - - - -
Title of Legally Responsible Person (must match 83b): DIV ISIOf y id exit __-
Name &Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Pho Number: 9'10-486-4864 _ — — -- --- --- --
- 313I a3
Signature of Legally esponsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretory, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B.
Item (6) of the NCG010000 permit.