NCC190543_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.