NCC191572_NOI Signed Certification_20190828

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources StonnwaterProgram
512N.Salisbury Street, 51hFloor
1612Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation,
oroertif0zztion/nany application, record, report, plan, urother uhoumentfiledorrequired tubcmaintained
under this Article ororule implementing this Article ... shall beguilty o/oClass 2misdemeanor which may
include ufine not toexceed ten thousand dollars ($20,OOO).
Underyenaltyof|aw,|certKythat(checkaUboxestuindicoteyourag/eemen8:
[� 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.
m/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 system, or those persons
directly responsible for gathering the information.
U | will abide byall conditions nfthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
y If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit,|will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
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�y | hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner amanindividual permit.
Name ofProject:
Legally Responsible Organizational Entity: 21 i i A
* Legally Responsible Person:
Title of LeRa4�oonsible Pe-Lson:
Signature: Vul— Date:
*/8VPORI4NTND7I. 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 mnsignatory requirements, see Part IV, Section 8,Item (6)ofthe NC6010D0Dpermit.