NCC240013_NOI Signed Certification_20240104

NCCyO1 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 NCDEMLRaormwater Program at:
Division of Energy, Mineral & Land Resources aormwater Program
512 N.Salisbury greet,6th Floor
1612 Mail Service Center
Raleigh, NC27699-1612
Per NCGeneral Satute 143-215.6B(i), any person who knowingly makes any falso 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 t his Artide. . . shall be guilty of a Gass 2 misdemeanor 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 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.
IX The information submitted in this NOI 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 gathering the information.
IX I will abide by all conditions of the NO3010000 General Permit and the approved Erosion and
diment Control Ran.
® If the approved Erosion and Sediment Control Ran is not compliant with Part II (aormwater Pollution
Prevention Ran)of the NOS010000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
IN I hereby request coverage under the NOJ10000 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.
Name of Project: Turnbull Road Lot 5
Legally Responsible Organizational Entity: Dreamworks Construction, Inc.
* Legally Responsible Person: Marion Bledsoe
Title of Legally Responsible Person: President
Sgnature: �U�✓ia, % Date: 12/29/23
* 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 Part IV, Section a Item(6) of the NO3910000 permit.
For more information on signatory requirements see Part IV, Sbction B, Item(6)of the NCG010000 permit.