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HomeMy WebLinkAboutNCC242117_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): ....' ��.=� • 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 • 1I 0 11 I