NCC241468_NOI Signed Certification_20240515

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 S120 check if paying by check)
at
Division of Energy, Mineral& Land Resources Stormwater Program
512 N_Salisbury Streit,t Floor(Office 640K)
1617 Mail Service Center
Raleigh, NC 27699 1612
THE FORM YOU MAIL MUST 8l COMPLL:EU ',Atari AP UKIGIN AL SIGNATURE(NOT DIGITM) (40 CFR 122?2)
Per NC General Statute 14.3-21.5.6R(i), any person who knowingly makes any false statement, representution, 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 donors($10,O00).
Under penalty of raw, I certify that(check all boxes to indicate your agreement!:
lEr 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.
Cyr The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, and complete
based cm my inquiry at the person or persons who manage the system, or those persons directty responsible for
gathering the information_
dI will abide by all conditions of the NCG0100Of Genera?Permit and the approved Erosion and Sediment Control
Plan.
NZ( It the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG01O0OO General Permit,I will nonetheless ensure that all renditions of Part I I of the
permit are met on the project at all times.
Er I hereby request coverage under the %.GOID 'fJ Generai7Prmit 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 I must match A1o): I o9 J ,L _ »��n C_+
S etific Lot Numbers(must mufti, : �2-Alb):
P ( )
Permitter (must match Al): it h e a- Gis 1t7?(C [_•
l(pally Responsible Person (mutt match R2& R3): .' a I a7 ' -h
Title of Legally Responsible Person(must match 83b): f)Te5jden,t
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person: 5q7;j 04 E.t( 1 d�
S- J
Phone Number: �. - 4c,72
T
f 7,./a y f - �/) 5//C'/Z
Signature afi.eg lly Responsible Person or Authorized Individual Date
IMPORTANT NOTE: this farm must he signed by n responsible cmmorate officer that owns or Operates the construe-non activity,
such as a aresidcnt,secretory, treasurer,or vice president,or a manager that is authorized in accordance with Part iV,Section B,
Item(t)of Orr NCG010000 Gjerrnit,