NCC191641_NOI Signed Certification_20190830

NCG0J, Notice of h-iten't (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO1.
Then, ni the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) 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 NC General Statute 143-215.6B (i), any person who knowingly makes ari statement, representation,
or certification in any application, record, report, plan, or other document filled 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 aftne not to exceed ten thousand dollars ($10,000).
Under alty of law, I certify that (check all boxes to infflcate, your agreement):
i aim 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.
The information submitted in this N01 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.
I will abide by all conditions of the NCG01.0iQ00 Gerieirgi Pef'rTlit and the approved Erosion and
Sediment Control Plan,
If the approved Erosion and Sediment Control Plan is not compliant with Part H (Stormwater Pollution
Prevention Plan) of the I GODEM00 General Flerrrdt, I will nonetheless ensure that all conditions of
Part il of the permit are met on the project at all times.
I hereby request coverage under the N0.301.0000 Genera� Perrnfl- and understand that coverage under
this permit MH constitute the permit
requirements for the discharge(s) and is enforceable in the
same manner as an individual permit,
A"
'4ame of Project:
Legally Responsible Organizational Entity:
* Legally Responsible Person: V-e'kNr1Cf%'"N 12" k
Title of Legally ResponsiWQPe
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, Itern (6) of the NCG010000 permit.
imp