NCC190451_NOI Signed Certification_20190603

NCG01 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEIVILR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 1h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NCGeneral Statute 143-21S.68(i), any person who knowingly makes onyfalse statement, representation,
or certification in any application, record, report,plan, orother documentfiledm required tobemaintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include o fine not to exceed ten thousand dollars (S1L\DDU).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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ua 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.
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The information Submitted in this NO[ 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.
01 | will abide by all conditions ofthe NCGOI,0000 General Permit and the approved Erosion and
Sediment Control Plan.
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m� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General P.ermit, | will nonetheless ensure that all conditions of
Part || of the permit are met on the project at all times.
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o� | hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asan individual permit.
Name ofProject: CONTRACT 2018-O2O. SUMMIT AVENUE STREETSCApES
Legally Responsible Organizational Entity: CITY DFGREEN8BORO
* Legally Responsible Person: TEO KALLAM, PE
Title of Legally Responsible Person: ENGINEERING DIVISION MANAGER
Signature: AJ klage-�, Date: 126lq
IMPORTANT NOTE: Thisform 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.
For more information on signatory requirements, see Part IV, Section 8, Item/61of the N[G02D0O0permit.