NCC232128_NOI Signed Certification_20230823

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 DLMLR Stormwater Program (with 0100 check If paying by check) at.
Division of Energy, Mineral & Land Resource, ',Iorrnwater Program
S12 N. Salisbury Street, 6" Floor (Office 640K)
1612 Mall Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR AI'I'I ICAIION HAS BEEN ACCEPTED AS COMPLErE
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 mukec 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
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 construction activities of this project, for satisfying the requirerr - -- ,
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Q✓ The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and compiere
based on my inquiry of the person or persons who manage the system, or those persons directly resporsioie for
gathering the information.
Q✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Contrai
Plan.
(]✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
E✓ 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.
Project Name (must match Ala): Novant Health Family Clinic North Wilmington
Specific Lot Numbers (must match Alb): N/A
Permittee (must match 81): Novant Health, Inc.
Legally Responsible Person (must match 82 & 83): Mary Anna Phillips
Title of Legally Responsible Person (must match 83b): Manager of Design & Construction Operations
Print Name &Title of Signed if Authorized
Individual Differs from Legally Responsible Person: N/A
Phone Number: 843-602-1811
/w i
Signature of Legally esponsible Person or Authorized ndividual Dat
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president secretary, treasurer, or vice president, or a manager that is authorized in accordance with Port IV, Section 8,
Item (6)of the NCG010000 permit.