NCC232910_NOI Signed Certification_20230927

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, com���m�n and upload to�e�e� �o N0
�e�maU1�o�n����1� NCD�N0Stormwater Program (with $1—check�����e� at�'
Di�sionofEner�, Mineral /� Land Resources � nn aterProgra ^
5IJN.Salisbury Street, 6m Floor(Office 640K)
l01Z Mail Service Center
Raleigh, N[2769y-1612
0O NOT MAIL THIS FORM OA PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE
THE GORKHYK30M�AIL&80STBE COMPLETED WITH AN{3RIGV0d��LS|��NAJW0EYNOTC}|GUTAQ [40CFWI22'-2]
Per V[Genero/Jbotute143'22I680l any person who knowingly makes onytobe statement, representation, or
certification/n any application, record, report, plan, orother do unentƒ edoroequinedtobenohvto/nedundert his
Article oro rule implementing this Article. . . shall be guilty 4fo Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars/$2[l8O0/.
Under penalty of|avv' | certify that (check all boxes to indicate your agreement):
D' / amthepesonrespunsib|efortheconstructiunartiv/tiesofthispro/ect'forsatbfvingtherequirernentrofthis
permit, and for any civil orcrirnina| penalties incurred due to violations of this permit.
| u[ The information submitted in this NO/ is, to the best ofmy know/edge and belief,true accurate and complete
based onnoy inquiry of the person or persons who nnana8ethe uystenn' or those persons directly responsible for
gathering the 'information..
01-11w�-ill abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
/fthe approved Erosion and Sediment Control Plan is not compliant with Part || (Sto/mnvaterPollution
Prevention Plan) |wi|| nonetheless `
' , en�urethata|| cond/tionsofPart |/ ofthe
er it are met on the project at all times.
�~1 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 A2o): � ��^*,t� Z�` 'r»��_ � ��^L 2 *�--
Specific_Lot Numbers(must nna�chA2b):
�
Pemnittee/nnus�
` �o�_�¢ '��|Q / i ��
Legal� �spon ���ePeoonimustmm�hfQ� �B'
' `�' .�
Title of Legally Responsible Person (must match 83b}: ^ ' °�k^��� v~—
PhntMameE&Tit/eofSi8nedifAuthorized
_Individual Differs from LeQaUyResponsib|e �ersun� ^/ »��' 7~~ � ~r-
- (?ee9j�r-e/ . x�� r=. ~. ~
Phone Number:
ono __~Signatun�ofLeoaUyResponsib|��"rs
«dua/ � Date
* VNPORTA/V7NOTE., Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such cis opxsiden( secretary, treasurer, or vice president, oro manager that is authorized/h accordance with Part IV,Section fl
item(6)qf the NOS02OQD0permit.