NCC190114_NOI Signed Certification_20190426

NCG01 III' oticle of Irrtent (N01) Certifi`at ior"i Forrr'i
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMILR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Sa:l'isbury Street, 6'r' Floor
1612 Mail Service Center
M330=��
Per NC General Statute 143-215,68 (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 four boxes to indicate your agreement:
I arri the person responsible, for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties iricurred due to violations of this
permit.
The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on my inq,uiry of the person or persons who manage the systern, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the rionf""r P(,�i nn'_i 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 N(.',f,ul Lx000 r nmer it flermO, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the protect at all times,
I hereby request coverage Linder the 11114( C)O111"X)HO Pui, i rw, and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
sarne mainner as an individual permit.
Legally Responsible Organizational Entity::
Legally Responsible Person:
.. . . ......... . .. . ....
Signature: c y Date:
*IMPORTANTNOTE: 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 B, Item (6) of the NCGO10000 permit.