NCC233325_NOI Signed Certification_20231128

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 DEMLR Stormwater Program (with$120 check if paying by check)
at:
Division of Energy,Mineral&Land Resources Storrnwater Program
512 N, Salisbury Street,60,Floor(Office 640K)
1612 Mail Service Center
Raleigh,NC 27699-1612
THEFORMYWMAIL MUST BE COMPLETE WITH AN ORIGINAL S1GNATNNE(Naft GITAL)[40 CFR 122.221
Per NC General Statute 143-215.68 fi), any person who knowingly makes 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 to
exceed ten thousand dollars($10,000).
Under natty 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 requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
the information submitted in this NO1 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
athering the information.
03
I will abide by all conditions of the NCG0100Q0 General Permit and the approved Erosion and Sediment Control
P h.
If the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Pollution
Pre ention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
Pre
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.
Project Name(must matchA1a): LOT i3 Oa_ &s .e
Specific Lot Numbers(must match Alb):
Permittee(must match 81)t PM tg t, b jij,2 rtS (IC
Legally Responsible. Person(must match 62&83) SW, O4/1,Vifir
Title of Legally Responsible Person(must match B3b): 111.._..
Print Name&Title of Signed if Authorized (
Individual Differs from Legally Responsible Person:Ji i 0616
PhoneNum : ! '7
ifei37;1;3
Signature of Legally Responsible Person or Authorized individual Date
IMPORTANT NOTE: This form must be signed bya responsible corporate officer that owns or operates the construction activity,
such as o president,secretary, treasurer,or vice president,or a manager that is authorized In accordance with Part IV,Section B,
Item(6)of the NCGO10000 permit.