NCC231784_NOI Signed Certification_20230609

NCG01 Notice of Intent (NOk) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form to the NC DEIVILR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, k4inera! & Land Resources StormwaterProgram
S1JN.Salisbury Street,6h Floor(Office 64OK)
1612 Mail Service Center
Raleigh, N[276y9-1612
0Ky NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE,
THE FORM YOU MAIL MUST BE COMPKGTE0WIT14 Ay0 ORIGINAL SIGNATURE(NOT DIGITAL) (40[FRI22.22)
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfulse statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article nro rule implementing this Article. . . shall be guilty ofo Class J misdemeanor which may include o0nenot to
exceed ten thousand dn&co ($2{lDUD}. '
Underp Ityof|axK | certify that (check all boxes to indicate your o0reenoent):
| arnthe person responsible for the construction activities ofthis project,for satisfying the requirements of this
it andforanycixi| orcrimina| pena|tiesincurredduetovio|ationsofthispermit.
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The information submitted in this N01 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.
-t-� | vvi|iabidebya|| conditionsoftheNCG0lUUOUGenera| PerrnitandtheapprnvedErosionandSedimentContro|
Plan.
?� |ftheapprovedErosionandSedinnentContro| P{anisnotcump|iantwithPart || /StornnwaterPoUution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
pe it are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit,
Name of Project (must match Alo):
Specific LotNunnbers (rnuz�nnm�tAlb)�
- _'--
Legally Responsible Organizational Entity(must match 81):_ ����7��^ �� "��� ~�p�^_ e_
-_ '
LeQa||yResponoib|ePerson (/nustnnotch82QD3):
]
~ J
Title Le
gally Responsible Person (must match �
8� : u�--+
Name O/Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
-
Phone ~~
Sign Legally Re b|e Authorized Date �
° 0MPCRTANTIVO7E., Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such aso president. secretary, treasurer,m vice president, oromanager that bauthorized in accordance with Part IV,Section B,
Item(6)gf the NOG020000permit.