NCC231748_NOI Signed Certification_20230607

NCGO1 Notice of Intent (NOi) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMUR Stormwatcr Program (with S100 check if paying by check)at
Division of Energy. Mineral &Land Resources Storrnwater Program
512 N. Salisbury Street,&' floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 2/699 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 122.22]
Per NC General Statute 143-21.5.68(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 o fine not to
exceed ten thousand dollars ($10,000)
Under penalty of law, I certify that(check all boxes to indicate your agreement
▪ I am the person responsible for the construct:on activities of this protect,for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
O 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.
❑✓ I will abide by all conditions of the NCGO10000 General Pet:nit and the approved Erosion and Sediment Control
Plan.
Q✓ If the approved Lrosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCGU11,0X,I Cier:eral Permit, l will nonetheless ensure that all conditions of Part II of the
permit arc met on the project at all times.
ED I hereby request coverage under the NCGOIO000(dermal Pet wit and understand that coverage under this
permit will constitute the permit requirements for the discharges)and is enforceable in the same manner as an
individual permit
Project Name (must match Ala): Bailey Residence
Specific. I of Numbers(must match A1bi:
Perrnittcc (must match 81): Ronald & Jamie Bailey
Legally Responsible Person (must match B2& 831: Ronald & Jamie Bailey
Title of Legally Responsible Person (must match 83b'I: Ronald & Jamie Bailey
Print Name&Title of Signed if Authori7ea
Individual Differs from Legally Responsible Person:
Phone Number: 336-945-6831
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lc1 l�
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nature of Legally t�sporsible Person or horized Individual Date
IMPORTANT NOTE: This farm must be signed by a responsible corporate offxer that owns or operates the construction UCtivity,
such as a are-sident, secretory, treasurer, or vice president,or a manager that is aulhorima in accordance with Port N,Section B.
item(6)of the NCG01(XXX)permit.