NCC240452_NOI Signed Certification_20240220

NCG01 Notice of Intent KNOA8Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form to the NC DEKHLR Stormvvater Program (with $120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources Stormm/a0erProgram
512',N. Salisbury Street,61, Floor(Office 64OK)
1G12 Mail Service Center
Raleigh, NCI?689'1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40[FRI32'22l
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article oro rule implementing this Article. . . shall be guilty ofo Class 2 misdemeanor which may include o fine not bo
exceed ten thousand dollars/$2{lDOO>.
Under penalty nf law, | certify that (check all boxes ko indicate your ogrmamment):
| annthepersonre�ponsib|efor�hecons�ructio� �ctivit�esoft��spn�ect forsatisfvin@Lhereguirementsofthis
7-~ ' '
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.
]FAIN I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
| If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
/ Prevention Plan) of the NCGO10000 General Permit, f will nonetheless ensure that all conditions of Part 11 of the
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 A2o\: 619 BnDokbe[rV Farm
Specific LotNumbers(/nostono�chAlb): 619
_ . _ '
Penni1tee(must match 82\� K�itchco' Inc
'
Legally Responsible Person (must match fQ& 83\: Geoffrey Mitchell
Title of Legally Responsible Person (must match B3b>: President
Print Name 6b Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
'
Phone Number:
336601
, �
Signa'urm , L��UyRenponoib|ePersom~� �d |ndiv�dua| � ' -��-��-�-����
- 0MPO0TANTNOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such cis opnskfent secretary, treasurer, or vice president, or manager that is authorized in accordance with Part/V,Section g'
Item(5)of the WCGO20Q0Dpermit.