NCC242117_NOI Signed Certification_20240715

111
NCGO1 Notice of Intent (N01) Certification Form
Directions: I
Print this form,complete,scan and upload to the electronic NOI.
Then,mail the original form to the NC DEMLR Stormwater Program(with$120 check if paying by check) 1
at: ,i
Division of Energy,Mineral&Land Resources Stormwater Program II512 N.Salisbury Street,6th Floor(Office 640K) III
1612 Mail Service Center
Raleigh,NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)(40 CFR 122.221 '.I
anyperson who knowingly makes any false statement,representation,or ail
• Per NC General Statute 143-215.66(i), .
't 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 dollars($10,000). I .
Under penalty of law,I certify that(check all boxes to indicate your agreement): ,
Q 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. '
0' The information submitted in this NOI is,to the best of my knowledge and belief,true,accurate,
d neatly and completeple for '..i
based on my inquiry of the person or persons who manage the system,or those persons '..,
I willherind the information.
llconditions ��•
approved Erosion and Sediment Control
© I abide by all of the NCGO10000 General Permit and the .
Plan. Mil
0 If the approvedlaErosion and SedimentGeneral Pertrol lan mit's not compliant I will nonetheless ensurethat all(Stormwater
II of the ...'
perm tPreventionae Plan)of the NCG ..,
�— permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this ill
❑ permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an Ina
MN
individual permit. / 1////
t `� �� I...,
Project Name(must match Aloj:
�, �,\��. III/
r � _ (-t ( /1111
Specific Lot Numbers(must match Alb): ....'
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• Permittee(must match B.1): ....,
in Legally Responsible Person
must match B2 63): ,....
Responsible Person(must match B3b): ,11��
Legally Resp '..M
� Title of Leg V
Print Name&Title of Signed if Authorized Person: 11111,
gi
Individual Differs from Legally Responsible
cn Ii111l
�`� --1 ) ,� is/1//,
N
Phone Numb
Date �1111111�
q of Legally Responsible Person or Authorized Individual ,ores the construction activity, .®1111
SignatUr 1111Mon
form must be signed by a responsible corporate over that owns or ape
This manager
that is authorized in accordance with Part iV,Section B, J11111111
. tMpaRTANT NPtreasurer,or vice president,or a m°°a9
such as a president,seueta ermit.
_._.nIIUAU�Item(6)of the NCG010000 p .'112 23 ?I 25' ?ti
5 6 7 I 9 •
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