NCC190452_NOI Signed Certification_20190603

NCG01 Notice of Intent (N01) Certification Form
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Directions:
Print this form, complete,scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street,6'h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
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Per/VC 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 ofine not,to exceed ten thousand dollars!f$10,000).
Under penalty of law, I certify that(check all boxes to indicate Your agreement):
X I ami the person responsible for the construction activities of this project,for satisfying the
requirernents of this permit, arid for any civil or criminal penalties incurred due to violations of this
permit.
M The information Submitted in this N01 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.
N I wil'il abide by all conditions of the NCGOI.0000 General Pern-flL and the approved Erosion and
Sediment Control Plan.
IN if the approved Erosion and Sediment Control Plan is not compliant with Part It (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Perrnit, I will nonetheless e11SUre that all conditions of
Part ll of the permit are met on the project at all times.
9 1 hereby request coverage under the NCGO10000 General P(,.-,ii,i,n,J,t and Understand that coverage under
this permit will WnStitUte the permit requirements for the discharge(s), and is enforceable in the,
same manner as at) individual permit.
Narne of Project: Leland Highway 17 Sewer Expansion 11 — Phase I
Legally Responsible Organizational Entity: 'Town of Leland
Legally Responsible Person: David.-Hollis
Title of Legally Responsible Person: Town YanagqL_
Signature: Date: 5/30/2019
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, !tern (6) of'the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section,B, Item (6)of the NCGO10000 permit.