NCC241630_NOI Signed Certification_20240530

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 S 120 check If paying by check)
at.
Divicinn of Energy,Mineral P.Land Resources Stormwater Program
S12 N.Salisbury Street,6^Floor(Office 640K)
1612 Mail Service Center
Raleigh,NC 27699-1612
THE FORM YOU MAIL MUST 8E COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)[40 CFR 122.22)
Per NC General Statute 143-215.68(i),any person who knowingly makes any false statement,representation,or
certification in any application,record,report,pion,or other document flied or required to be maintained under this
Ancoe or o 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).
Jndcr penalty or law,I certify that(check all boxes to indicate your agreement):
am the person responsible for the construction activities of this project,for satisfying the requirements of this
aermit,and for any civil or criminal penalties incurred due to violations of this permit.
yThe 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,
wil abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Nan
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 the
aermit are met on the project at all times.
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.Projecr Name(rnusrmotchAla): ��.JrteS a-4
5 A Ie-s/c.)0ke
Specific Lot Numbers(must match Al b):I-a4 !) 3—/31 131-a /a
Permlttee(must match B1): D,A. 140(.4,y-h ) �e.,c„
Legally Responsible Person(must match B2&83): E/,'i.,,A 19c1-LI ke/-Iv►--,
Title of Legally Responsible Person(must match 83b): V i Lt /°rest else—s 4
Print Name&Title of Signed of Authorized / /1A IV"- //�� .}/- 1
Individual Differs from Legally Responsible Person; Do se),(/l' / i ,e In ,4 l5 I itr� 5eCr�'7ar L\
Phone Number: 6I( _508 _ I 1 [[^^CC
Siena/lure Legal y Re onslble P on r(Authorized Individual ����/02
`
D
*
IMPORTANT NOTE: This form must be signed by o responsible corporate officer shot owns or operates tiro construction activity,
such as a president,secretory,treasurer,or vice president,or a manager that Is authorized In accordance with Port IV,Section 8,
Item(61 of the N00010000 permit.