NCC232405_NOI Signed Certification_20230809

NCGO1 Notice of Intent (NOI) C_rtification Form
Directions:
Print this form, complete, scan and upload t• the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Progr..m (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resource. Stormwater Program
512 N. Salisbury Street, 6th Floor(office 640K)
1612 Mail Service Cent:r
Raleigh, NC 27699-1610
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICA ION 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 143-215.68(i), any person who knowingly mak-s any false statement, representation, or
certification in any application, record, report,plan, or other document iled or required to be maintained under this
Article or a rule implementing this Article. . . shall be guilty of a Class 2 isdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your ag eement):
E I am the person responsible for the construction activities of th s project,for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to vi lations of this permit.
dThe information submitted in this NOI is,to the best of my kno ledge 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 NCG010000 General Permit -nd the approved Erosion and Sediment Control
Plan.
Er If the approved Erosion and Sediment Control Plan is not comp iant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will none-heless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
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permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit. CI AA pQ&
Project Name (must match Ala): GO1 � �.. 0�S CLt m L--0`-- I.I SS
Specific Lot Numbers (must match Alb): ( l LS
Permittee (must match 81): —K-H-6 L Ci. `TD1' -TO A-4 UR-_,
Legally Responsible Person (must match 82& 83): 04 H A 6 i.'4 '7M 7UA4Ll i..
Title of Legally Responsible Person (must match 83b): v )I
Print Name &Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number 9I0 S( Qf!7
Ov-- 0 R/0z/Z0z-3
Sign to e of Legally Responsible Person or utkh rized Indivi•ual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate o icer that owns or operates the construction activity,
such as a president,secretary, treasurer,or vice president, or a manager th it is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.