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HomeMy WebLinkAboutNCC190543_NOI Signed Certification_20190607 NCGO1 Notice of Intent 1) Certification Form 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,6th Floor 1612 Mail Service Center Raleigh, NC 27699-1612 i Per NC General Statute 143-215.6E(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). Uncle,penalty of law, I certify that(check all boxes to india alp your agreement): am the person responsible for the construction a 1:ivities of this project, for satisfying the requirements of this permit, and for any civil or criminal penalties incurred due to violations of this permit. 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 systern, or those persons directly responsible for gathering thy,,, iirforrnatl�un I will abide by all conditions of the 111t+ 11ik',�r_i.ieral Permit and the approved Erosion and Sediment Control Plan. If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution Prevention Plan)of the Ni (�QJ.MH"' D ;;qa�r��p r l,.w� Iaspgq I will nonetheless ensure that all conditions of Part II of the permit are met on the project at all time,. hereby request coverage under the t-1� t,�Y 1fr�41�b P� � n �� i' r�r,it and understand that coverage under this permit will constitute the permit requirements forthe discharge(s)and is enforceable in the same manner as an individual permit. Fc-b a•}-Name of Project: ,. 11'trh P ��� -9 t L5-w _ �ax •d r4-�.1 �owI... Legally Responsible Organizational Entity: -3CN -ffc,.Lls LLC * Legally Responsible Person; Title of Legally Responsible Person: VP a&rWe— Signature: Date (° *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 B, Item(6)of the NCGO10000 permit. For more information on signatory requirements,see Part IV,Section B, item(6)of the NCGO10000 permit.