NCC191997_NOI Signed Certification_20190924

NC,G01 Notice of Intent, (NOI) Certification Form
Directions:
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512 N. Salisbury Street, 6h Floor
1612 Vail Sexnce-Eenter--
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i,r 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 a fine not to exceed ten thousand dollars ($10,000).
Under p alty of law, I certify that (check all boxes to indicate your agreement):
;71arn the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penailties 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.
R"" 1: will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
D,'**" If the approved Erosion and Sediment Control Plan is, not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10,000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the, project at all times.
hereby request coverage under the NICG010000 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: KA i e-
Legally Responsible Organizational Entity:
A.,4 if,,'d2c -S:j� volt- A ve A Ag .tee* 4
Legally Responsible Persoin-, 6.a' V
Title of Legally Responsible Person: 0 &"C'
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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, Item (6) of the NCGO1OOOO permit.
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