NCC190046_NOI Signed Certification_20190416

NCGO1 Notice of Intent (NOI) Certification Form
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Directions:
Print this form,complete,scan and upload to the electronic NOL
Then,mail the original form to the NC DE MLR Stormwater Program at-
Division of Energy, Mineral&Land Resources Star water Program
512 N.Salisbury Street,fish Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
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Per NC General Statute 143-215.69(i), any person who knowingly makes any false statement,representation,
or certification in any application, record, report,plan,or other documentfiled 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(ichecl,r,allfi")ur boxes to indicir:iitip�,iW,oi,jr,r-Iglir,iE^ement):
I am the person responsible for the cmrmt.ruction activities of"this project,for satisfying the
requirements of this permit, and for any civil or crimiriall penalties incurred due to violations of this
,.permit.
11?1 The information submitted in this 11,101 is,to the best of my l(mowli�.7.,idge 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.
["[J/ I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
12 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCG010000 General er it, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
Bir 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,
Legally Responsible Organizational Entity; 4' RD LLC
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Legall, sp, 11 P ............
Signatu Date:417
IMPORTANT NOTE. This form must be signed by 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 accordance with Part IV,Section 8, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.