NCC242685_NOI Signed Certification_20240919

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electrons:NOI.
Then,mail the original form to the NC DEMLR Stormwater Program (with$12C check if paying by check)
at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE Fowl YOU MAIL MUST BE COMPLETED WIT AN ORIGINAL SIGNATURE(NOT DIGITAL) (40 CFR 122.221
Per NC General Statute 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 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).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
❑✓ 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,and complete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
gathering the information.
✓❑ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
❑✓ 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.
0✓ I hereby request coverage under the NCG010000 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.
Project Name (must match Ala): Dosher Memorial Hospital Main Campus ED Addition
Specific Lot Numbers(must match Alb):
Permittee(must match B2): Dosher Memorial Hospital
Legally Responsible Person (must match 82& 83): Lynda Stanley
Title of Legally Responsible Person (must match B3b): CEO
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone N mber: 910-45 800
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3 2.
Si ature bf Le!' Respons .I_ •erson or Authorized Individual D to
* IMPORTANT NOTE: This form must be signed.y a responsible corporate officer that owns or operates the construction activity,
such as a president,secretary,treasurer,or vice president, or a manager that is authorized in a:cordance with Part IV,Section B,
Item(6)of the NCG010000 permit.