NCC191726_NOI Signed Certification_20190905

NCGO1 Notice
ofIntent (N01) Certification
rtifiat° Form
Directions:
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 6vcheck) at:
Division ofEnergy, Mineral & Land Resources StormmmterProgram
512 N. Salisbury Street, G1h Floor
1612 Mail Service Center
Raleigh, NC27599-1612
Per NC General Statute 143-215.68 (i), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall baguilty ofmClass 2 misdemeanor which may
include mfine not boexceed ten thousand dollars /$20,ODD>.
Under penaltyoflaw, | certify that (check all boxes toindicate your aQreument:
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.
a� 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.
| will abide bvall conditions ofthe and the approved Erosion and
Sediment Control Plan.
�
�� ,, If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
OK | hereby request coverage under the and understand that coverage under
this pernm�vvi||constitute the parnnitrequirennentsforth�diochar8e(m)and isenforceable inthe
same manner as an individual permit.
Name ofProject: Senta Self StorM
Legally Responsible Organizational Entit�� y� '-----'--p----, Inc.
Legally Responsible Person: Jon T. Mildenburg
Title of LeE
Signature:
*IMPORTANT8OTE.'This form must besigned 6vo responsible corporate officer that owns uroperates the
construction activity, such usu president,secretary, treasurer, mrvice president,uromanager that /s
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, SectionB, Item (6)ufthe 0CGO1000Dpermit.