NCC190340_NOI Signed Certification_20190521

NCGO1 Notice of Intent (N01) Certification Foirm
Directions:
Print this form, complete, scan and upload to the electronic CA I.
Then, mail the original form to the NC DEMLR Storm,water Pro earn at.
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61" Floor
16,12 Mail Service,Center
Raieigh, NC 27699-1612
Per NC General Statute 143-215.6B(i), any person who knowingly makes airy 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 implemen tin g 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 agreernent):
I am the person responsible for the cons,tiruc�tion activities of this project, for satisfying the
requirements of this permit, arid for any civil or criminal penalties incurred due to,violations of this
permit,
DK- The information subrnitted in this IqU Is, to the best of my knowledge and belief; true, accurate, and
complete based on my inquiry of the person or per-sons who manage the systern, or those persons
directly responsible for gathering the information,
I will abide by all conditions of the I,K-.G010000 Genera4 Per it and the approved Erosion and
Sediment Control Plan.
19, If the approved Erosion and Sediment Control Plan is not compliant with, Part II (Stormwater Pollution
Prevention Plan) of the It;GO1.0000(3eneral Permit, l wHI nonetheless ensure that all conditions of
Part 11 of the permit are met on the, project at all times.
I&- I hereby request coverage under the NC,G01000,0 e,1 G '"rp,era I ID,er"mit and understand that coverage under
this, permit will constitute the permit requkementsfor the discharge(s) and is enforceable in the
sarne rrianner as an sncliOdUal permft.
Naime of Project.
Legally Responsible Organizational Entity:
Legally Responsible Pearson .
Title of Legally Respons,i erson, 4—
Si —Date:
IMPORTANT NOTE- This forays 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 NCG0100001 permit,