NCC191878_NOI Signed Certification_20190913

NCG01 Notice
f Intent (N01) Certification
rt~fit~ 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 of Energy,Mineral & Land Resources StormvvaterProgram
512 N. Salisbury Street, 6m Floor
1612Mail Service Center
Raleigh, NCZ7GQ9-l612
Per N[General Statute 143-215.6B (i{any person who knowingly makes onyhzlsestatement, representation,
orcertification /nany application, record, report, plan, u/other documentfiledm/required tobemaintained
under this Article orurule implementing this Article ... shall heguilty 4ƒoClass 2misdemeanor which may
include ofinenot toexceed ten thousand dollars ($1(lDOC).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
R1 I am the person responsible for the construction activities of this project, for satisfying the
requirements ofthis permit, and for any civil orcriminal penalties incurred due toviolations Vfthis
permit.
9 The information submitted in this N0 is, to the best of my knowledge and belief, true, accurate, and
complete based onmyinquiry mfthe person orpersons who manage the system, nrthmsepemmns
directly responsible for gathering the information.
03 | will abide bvall conditions ofthe KG0 10000 Gener,fl Peinrrdt and the approved Erosion and
Sediment Control Plan,
03 If the approved Erosion and Sediment Control Plan is riot compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the | will nonetheless ensure that all conditions of
Part Uofthe permit are met nnthe project atall times.
0] | hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
Name of Project: J Westmoreland Inc uzu/andfiU
Legally Responsible Organizational Entity: JWestmoreland Inc
* Legally Responsible Person:
Thomas Westmoreland
P fle's
Title of Legally Responsible Person: t Ae'I'A—
Signature
Date:
IMPORTANT NOTE: Thisformmust hesigned bvo responsible corporate officer that owns oroperates the
construction activity, such usmpresident, secretary, treasurer, orvice president, orumanager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, Section8, Item (6) of the NCGO10000 permit.