NCC241668_NOI Signed Certification_20240604

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Theqmail the original form to the N[ DEK4LRSturnnwmterProgrann (xv�h$12D check/f paying 6xcheck)
at:
Division of Energy, Mineral & Land Resources StonnwaterProgram
S12N. Salisbury Street, 6m Floor(Office G4OK)
1612 Mail Service Center
Raleigh, NC276Q9'1612
THE FORM YOU MAIL MUST @E COMPLETED WITH AN ORIGINAL SIGNATURE(00T DIGITAL) [40 CFR1J2'22)
Per N[General Statute 243-215.688i any person who knowingly makes ony/bbe statement, representation, n,
certification in any application, record, report, plan, or other documentfiled or required bobe maintained under this
Article or a rule implementing this Article. . . shot]be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($20,020).
Under |tyof|avv, | certify that (check all boxes to indicate your a8reennent):
[_�' | am the person responsible for the construction activities of this project,for satisfying the requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[�J 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
ering the information,
L] ivvU| abidebyaHconditionsoftheNCG01O000Genera| PernnitandtheapprovedErosionandSedimentContro|
P|
| �^ |ftheapprovedErosionandSedimentComtro| P|anisnotoomp|iantwithPart || (StonnwaterPuUution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
[_] Xrm it are met on the project at all times.
lhereby request coverage under the NCGO10000 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\�
'
Specific Lot Numbers (must match Alb):
Permittee (must match Bl):
Legal.ly Responsible Person (must match B2& B3):
Title of Legally Responsible Person (must match B3b):
Print Name 8'Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: ` "e^ ��
_ _~,+~
Svmv/Au/u-v/ Legm/ynespyvC*oe Person or*utnonzeonuowoua| Date
* 0MPOR74NTIVO7E This form must be signed byo 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/n accordance with Part IV,Section£C
Item(5)o/the NCGO2ODG0 permit.