NCC240463_NOI Signed Certification_20240219

NCGO1 Notice of Intent (NOI) Certification Form
Dli ec tlonN
Print this form, complete, sr Arl And upload to the elorfronit NO1
Then, mail the original form to the NI ICI MI R Stormwnter Progrnm (with S 12n rhar i if Doyfna by el>.c*)
AI
Division of I netgy, MInr1 AI ti, I and Recourf Pc rtt(r,nwstar Prr,►'.a'n
512 N, Salisbury Street, fr F lone (Office (,4rwl
Hit) Mall ServIt e ( enter
Raleigh, N( I/(,'i') I r,I I
THE FORM YOU MAIL MUST BE COMPLET'CI) WITH AN ORI(,INAI SIGNAfliPI (NO1 rnr,rrAt) fM) CFR 111 27)
Per NC General Statute 143-215.68(i), any person who knowingly rnukrs any false statement, repro,er'.1..r,r -;r
certification in ony application, record, report, plan, or other document filed or required to be malntainpri rr'ir" 'PIS
Article or a rule implementing this Article . . . shall be guilty of a Class 2 misdemeanor which may include a firer mot tO
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
7 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 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.
/I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
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 e
permit 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 match Ala): Novant Health Family Medical Clinic Greenfield
Specific Lot Numbers (must match A1b): Lots 12-19
Permittee (must match 81): Novant Health, Inc.
Legally Responsible Person (must match 82 & 83): AU itir S
Title of Legally Responsible Person (must match 83b): V St.
f
Print Name & Title of Signed if Authorized Ottou4i4
Individual Differs from Legally Responsible Person:
Phone Number: Sib z r O .... 1 V I 1
IP • '
Sin •g ature of Legally sponsitle Person or thorized Individual ate
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such oc a oresldent tPrratan, frprncllror .,..,r,... .__ .