NCC242160_NOI Signed Certification_20240717

N0001 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronicNOI.
Then, mail the original form to the NC MVP LRaormwater Program(with$120 check if paying byc heck)
at:
Division of Energy,Mineral&Land ibsourcesaormwater Program
512 N.Salisbury greet,6th Floor(Off ice 64019
1612 Mail&rvice Center
Raleigh,NC27699-1612
ME FORM YOU MAIL MUST BEOOMPLEmD WITH AN ORIGINAL SGNATUR (NOT DIGITAL)AL)C44 GAR 9 22.22]
Per NCGeneral Statute 143-295.6E(i), any person who knowingly makes any false statement,representation, or
certification in any application, record,report,plan, or other document filed or required to be maintained under this
Artlde or a rule implementing thisArtide. . .shall be guilty of a Class 2 misdemeanor which may indude a fine not to
exceed ten thousand collars($10,000).
Under penalty of law,I certify that(check all boxes to indicate your agreement):
EY'I am the person responsible
esponsible for the construction activities of this project,for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
[,' The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate,and complete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
gathering the information.
E] I will abide by all conditions of the NO3010000 General F armit and the approved Erosion and Sbdiment(bntrol
Ran,
[f If the approved Erosion and Sbdiment Cbntroi Plan isnot compliant with Part II(Stormwater pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
[ I hereby request coverage a under the NOGD1000 0 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Leg cty ted4zes Prise LI /.4.+-s
Project Name(must match Ala): SOLI-.$oo, $io- r! 'i _ Sq! 50 4- -.5. .). S-)9
SDI- 5C) ". 5'to--s ri, srq-Sp,, s qd,sy , S iP -S'r/, S'7ly-s- �,S7S
�edfic Lot Numbers(must match Alb):
ss.,), 5q '-Se3, 5gi,- S42, toi , 4003,110gt 1ntZ, l, 0E
Faermittee(must match 81): C oYt 4- ► �.
Legally Responsible Parson(mud match B2&83): (,h(\s4t'ic. E C c k
Title of al! %sponsible FI'rson{must match an C e Si_
Print Name&Title of Sgned if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: tg 1'c --)g T)9O
Sgnature of Legally sib rson or Authorized Individual --.2) lb)a). '
t
Dat
* IMPORTANT NOTE This form must be signed by a responsible corporate officer that owns or operates the cona'ni ion activity,
such as a prudent,secretary,treasurer,or vice president,ore manager that is authorized in accordance with Part IV,action B,
Item(6)of the NCG010000 permit.
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