NCC191992_NOI Signed Certification_20190925

|Dn-2-' /u
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 $100 check if paying by check) at:
Division of Energy, Mineral & Land Resouues8tonnvvater Program
S12N.Salisbury Street, 6mFloor (Office 640K)
l612Mail Service Center
Raleigh, NC 27699-1612
DO NOTMAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per N[General Statute 24J`32fi6B (i),any person who knowingly makes uny/blsestatement, representation,
mrcertification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$I8DOCV.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
�5 1 am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or crir-ninal penalties incurred due to violations of this
per/nit.
10^einformatiunsubmittedinthisN0|is,tothebestofmyknow|edgeandhe|iettrue,accurate,ond
~ cornplete based on my inquiry of the person or persons who manage the systern, or those persons
directly responsible for gathering the information.
| will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion arid
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.
| hereby request coverage under the NCGO10000 General Permit and Understand that coverage under
/m
' this perrnit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
Legally Responsible Organizational Entity- S'C\
Legally Responsible Person: D /e-\ \-.<'� ,v�~//
Title of Le ry
*Print Name and Title of Signed ifAuth izedlndividuol
Phone Number:
IMPORTANT NOTE: This/onnmust besigned 6yoresponsible corporate officer that owns oroperates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.