NCC190056_NOI Signed Certification_20190417

NCGO1 Notice ofintent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic 1\101.
Then, mail the original form to the NC DEMLR Storrnwater Program at:
Division of Energy, Mineral & Land ReSOLlf-CPS Storrnwater Program,
512 W Salisbury Street, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-2.15.6B(i), ony 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 four boxes to indicate your agreement):
K 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.
KI 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.
K I will abide by all conditions of the NOG010000 General Permit and the approved Erosion and
Sediment Control Plan.
K If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Pairt 11 of the permit are met on the project at all times.
1Z I hereby request coverage under the NCG(tIOOOO General Perrnit and understand that coverage under
this permit will constitute the permit requirernents for the discharge(s) and is enforceable in the
same manner as an individual permit.
Legally Responsible Organizational Entity: COUnty of Stanly
Legally Responsible Persorl'. Andy L.Licas, County Manager
Signature: Date:
-fA 113-
IMPORTANTIVOTE. This form must be signed by a responsible corporate officer that owns or operates the
C0175trUCtiOn activity,such OS a president, secretory, treasurer, or vice president, or a manager that is
authorized in occordonce 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 NCGO1OOOO permit,