NCC242689_NOI Signed Certification_20240830

NCGO1 Notice of Intent(N01)Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOI.
Then,mall the original form to the NC DENIM Stormwater Program(with$120 check if paying by check)
at:
Division of Energy,Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,6"Floor(Office 640K)
1612 Mall Service Center
Raleigh,NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITALI(40 CFR 122.22)
Per NC GeneralStotute 143-215.6E(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
Article or o rule Implementing this Article...shall be guilty of a Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars($10.000).
Under nasty of law,I certify that(check all boxes to Indicate your agreement):
lam 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.
dThe 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.
gi I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
-/ Plan.
L.gl 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
/permit are met on the project at all times.
Di I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges)and Is enforceable in the same manner as an
individual permit.
Project Name(must match Ala):C'IDVCJ(fl t:g Ctu_b_- q3l El C
Specific Lot Numbers(must match Alb): •
q3
Permittee(must match gl): (y' � Yu a � [�,hi1D'/hu I &
(7 t
A
Legally Responsible Person(must match B2&B3): Marl Y L)
Title of Legally Responsible Person(must match 83b): Y[LQ
Print Name&Title of Signed If Authorized
Individual Differs from Legally Responsible Person:
Phone Number: (qVA) ga(Q_}V ,,`�s�q-� ,I
Signature of Legally Responsible Person or Authorized Individual �Al2.(01 202y
•IMPORTANT ROTE•This form must be signed by a responsible corporate officer that owns ar operates the construction activity,
such as a president,secretary,treasurer,or vice preeW erE or o manager that Is authorized in accordance with Part Iv,Section B,
Item(6)of the NCG010000permit.