NCC191650_NOI Signed Certification_20190906

NCG01 Notice of Intent (NOU) Certification 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 by check) at:
Division ofEnergy, Mineral & Land Resources SLormwaterProgram
S1JN.Salisbury Street, 6*Floor
1612Mail Service Center
Raleigh, NC27699-1613
Per NC General Statute 143-215,6B (i), any person who knowingly makes anyfialse statement, representation,
or certification in any application, record, report, plan, or other documentfiled 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 ufine not tnexceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
3 1 am the person responsible for the construction activities of this project, for satisfying the
requirernents of this permit, and for any civil or criminal penalties incurred due to violations of this
permit
E2� The information submitted in this N0 is, tothe best ofmyknowledge 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.
13a | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
ER 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 Uofthe permit are met onthe project atall times.
10 | hereby request coverage Linder the NCGO10000 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 ayanindividual permit.
Name ofProject: Norton Field Improvements
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Title of Legally Respo
Signature:
Western Carolina University
Joe Walker, PE
�o Management
non ~`
8'/`sk
*IMPORTANT NOTE: Thisform must be signed byoresponsible corporate officer that owns moperates 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 onsignatory requirements, see Part IV, Section 8,Item (6)ofthe NCG01O000permit,