NCC242692_NOI Signed Certification_20240905

NCGO1 Noti e •f In ent (NOI) Certification Form
Directions:
Print this form, corn olete,scan and upload to the electronic NOI.
Then, mail the original form to the NC D MLR Stormwater Program (with $120 check if paying by check)
at:
Division of Energy, Mi eral & Land Resources Stormwater Program
512 N. Sali.bury Street, 6th Floor(Office 640K)
612 Mail Service Center
sleigh, NC 27699-1612
THE FO M YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Pe NC General Statute 143-215.6E(I), any perso who knowingly makes any false statement, representation, or
ce tification in any app'fication, record, report,pion, or other document filed or required to be maintained under this
Ar icle or a rule implementing this Article. . .sha I be g ilty of a Class 2 misdemeanor which may include a fine not to
ex eed ten th iusand dollars ($10,000).
U der penalt of law, I certify that(check all bp'es to ndicate your agreement):
E I am t e person responsible for the con ruction activities of this project,for satisfying the requirements of this
permi ,and fo any civil or criminal pen ties I curred due to violations of th s permit., I
✓® The i formatio submitted in this NOI isI to th- best of my knowledge and'be lief,true, accurate, and complete
base. on my inquiry of the person br pe'sons ho manage the system, or those persons directly responsible for
gathe ing the information.
t, I will bide by ll conditions of the NCGO 000 General Permit and the approved Erosion and Sediment Control
Plan.
151 If the pprove Erosion and Sediment Ctntrol Plan is not compliant with Part II (Stormwater Pollution
Preve tion Pla ')of the NCG010000 Gen ral P rmit, I will nonetheless ensur that all conditions of Part II of the
permi are me on the project at all time..
1 I here.y reque-t coverage under the NC+301.000 General Permit and unders and that coverage under this
permit will constitute the permit require—lent for the discharge(s)and is enforceable in the same manner as an
indivi.ual permit.
Project Name (must match Ala): Milani Equipment Rental Retail Sales Building
Specific Lot Numbers (must match Alb);
Permittee must mqtch 61): Milam Equipment Rental, LLC
Legally Re,ponsible Person (must match ;B2 B3): Edmond Milam
Title of Legally Responsible Person (must match B3b): Owner
Print Name &Title of Signed if Authorized I
Individual Differs from Legally Responsible Person:
Phone Number: 9 0-371-998 li 1
/7
II
1 ,d 9-do4?
I ' tur of Legally R sponsi le!,P s or A thorized Individual Date
* MPORTANT NOTE: This form must be si ed y a responsible corporate officer that owns or operates the construction activity,
•uch as a president,secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,Section 8,
tern(6)of th1e NCG010I 00 permit.