NCC233471_NOI Signed Certification_20231127

Print this form,complete, scan end upload to the electronic NOl-
Then, mail the original form to the NC DE MtR Stormwater Program (with$120 check if paying by check)
at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N. Salisbury Street,64, Fleur(Office 64010
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC Ge ewl Srotute.143-215,68 (4J, any person who kriowing'y makes any false stotemerit, repte$entotidn, or
Cert> rkm ir7 any application, record, report, plan or other,documerif/led or required to be maintoined under thit
Article or o rule kropiemealr'ng this ArUGl..- - , shoh be guilty of o Gass 2 miRierneartor which may include o fine not to
exceed ten fvusorWd doOlars 690.000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
E✓ 1 am the person responsible for 1 he Construction act-rvities of this project, for satisfying the requirements of thi 5
permit,�n(t for ammm ovit or criminal pe nalric5 Incurred due to v,olati4{i 5 of this Permit.
111 Tile inFarm:'tion sub ittcd in this NOI is,to the hest of my knowledge and belief, true,accurate, and complete
tried on my inquiry of the person or persons why maiwge the system, or those persons directly responsible For
gathoring the iglormation.
El I will abide by ail cor titions of the and the approved Erosion and Sediment Gomel
el
Pla►•
0 If the approved Erosion and Sediment control Plan is not compliant with Par: II (Stormwwter Pollution
Prevention Plan}attic ,1 will nonetheless ensutt that all conditions of Part II of the
permit art Met on the prbjtct at all times-
✓Q I hereby lertuert coverage under the and understand that coverage undor this
permit will constitute the permit rr*qui retreats for the dischargels}and is enforCeah:r in the.sa Me ma n ner as an
individual perrnit
Project Name (envy motCh A1o): 44E cfl c 147-e,Lc --
ifs U t Numbers 1rrru$Umulch A1b): _6 4-
Perms(must mc,tch BI): 4( Cil1G _1 n c-
LA-molly Responsible Person I mutt match 1 & 83E: ti97 v1jec e4../__A_
Title of Legally Responsible Person (must match 83b}: ,‹-et oj ce, eif Pont Name $v Title of Signed if Authorised
Individual Differs from Legally Responsible Pert_ _ _ -
Phoele Number: (336 7- C; —
11 12/2_3
.....4— \
_.9--4144 try
Signature of LeOlty RAsponsib e Person or-Authorized Individual Date
• 'WOMAN!'NOR: Th6form mall be signed by a reSpilnsible carpo(v?Le of f icier ihrlt Owns or operates the fAmtffrctiarr OCtMty,
surh Qs zr presiderrt,secretary, measurer,or vice pre.sident or a:Waiver Opt Es authorized in accordance with Pon W.Section B,
rte►n Mot the NC600000 permit