NCC191548_NOI Signed Certification_20190828

Notice is it
Directions:
Print this form, complete, scam and upload to the electronic ti p.
Then, mall the original form to the NC DIEMLR Stormwater Program (with :300 check if paying by check) at -
Division of Energy, Mineral & farad Resources Storimw ater Program
512 IN. Salisbury Street, 6111 Floor
:1612 I ail Service Center
Raleigh, NC 276994612
Per NC General Statute .14. -21.5. fs), any person Who knowingly makes anyfalse .statement, representation,
or cert�ftcation in any application, record, report, plan, or other acumeant she ar requfre�t �o maintained
vender this Article or a rule implementing this Article. . shall be guilty of a Class 2 misdemeanor iwhfch rraay
include a fine not to exceed tern thousand dollars ($,1 , ).
Under penalty of law, p certify that (check all boxes to indicate your agreement):
- � p arnr, the person responsible for the construction activities of thus project, for satisfying the
requirements of this perrmnut, and for any cuwrpl or crlrmnunall pnenaUtles pmncu.arred due to violations of this
perrmnut.
The information suabun"ut,ued ki this NU is, to the best of my knowledge and belief, truce, accurate, and
comp lIete based on tummy unapuury of the person or persons who manage the system, or those persons
dprectly respounsplbUe for gathedng the unforn°aatpaun.
U will abide by all co ndutmns of the
Sediment Control Plan,
and tine approved Erosion and
If the approved Erosiorl arid Se� 4neu„nt Control Plan is not compliant rle ii::ilii�-t IIB (Strr,i°'n' wa,kel, I°:wcUl:Ufliwr
Prevention Plan) of the U will nonethele5s e sins e that aH of
Part ll of the permit are met cir,, the pr°°aject at all times.
[_ U hereby request coverage ui!ider tics^ and a iindei sta nd that co%,e�,,sgle under.
this perrrnut uwrlll constotuste Che I°;terunnrt requirements for the duscharge(s) ]�i,td us crrfrarcen!flDe fi� the
same manner as an Undvr dw,nll p�!'.wer.o,°na.
Name of Pro jem . m"._� u
Im
ILe al0y Responsible Organizational Entity:
* Legally Responsible Person:
Title of (Legally Responsible Persaro; a iv 4,
M
t r ' rr This farm waist be signed by a responsible corporate Qfficer 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, Items () of the NCGO.10000 permit.
For more information an signatory requirements, see Part 3tl, Section B, Item () of the NCGO10000 permit.