NCC192022_NOI Signed Certification_20190924

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $10,0 check if paying by check) at:
Division of Energy, Mineral & Land Resources Storrnwater Program
512 N. Salisbury Street, 6t' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEJ
REVIEWED AND ACCEPTED AS COMPLETE"
Per NC General Statute 143-215.6B (i), any person who knowingly makes arty 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 afine not to exceed ten thousand dollars ($10,000).
Und nalty of law, I certify that (check all boxes to indicate your agreement):
71 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.
EVThe 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 NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
N/ if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
I" /Part 11 of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 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:
Legally Responsible Organizational Entity: t,..1,
Legally Responsible Person: i6A-MY4
Title of Legally Responsible Per 6ny,
*Signature: Date:
*Print Name and Title IfSignedifAuthorized
f Si
f m
Individual Differs f m Permittee:
Phone Number:
* 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 NCG010000 permit,
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit.