NCC191712_NOI Signed Certification_20190905

NCGGL1 Noti IIntent (N01) Certification Forrn
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Print this form, complete, scan and upload to the electronic NO1.
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 Stormwater Program
512 N. Salisbury Street, 6"' Floor
1612 MaH Service Center
Raleigh, NC 27699-161 2
Per NC General Statute 143-215.613 (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,(00).
Under enallty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of tMs 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 system, or those persons
directly responsible for gathering the information,
I will abide by all conditions of the 1 C.'(30100001 General Permit and the approved Erosion and
Sediment Control Plan.
M`4 if the approved Erosion and Sediment Control Plan is not compliant with Part il (Stormwater Pollution
Prevention Plan) of the N " O - CG'V1 " 1 - 000 - G - e - neia , , ' I " Per�rrdt, I will nonetheless ensure that all conditions of
Part 11 of the permit are et on the project at all times.
LrnI hereby request �coverage under the N0301.0000 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 as an individual permit.
Name of Project: _&okonI6 __0,100C,?�_Aj2je 9—/01/
Legally Responsible Organizational Entity;
Legally Responsible Persow,
"Title of Legally Responsible Person:
Signature: --Date:
IMPORTANT NOTE: This form must be signed by G 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 NCGOJOOOO permit.
For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCGO10000 permit.