NCC192030_NOI Signed Certification_20190926

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 StomowaterProgram
612N.Salisbury Street, 6mFloor (Office 64OK)
1612 Mail Service Center
DO NOT IMAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per N[General Statute 143-215.fB(i), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article orarule implementing this Article ... shall be guilty ofoClass 2misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
��.
Under penalty oflaw, | certify that (check all boxes toindicate your a8reen)ent):
n!I'~- | 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.
EL, --The information submitted in this N0 is, tothe best ofmy 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.
[l_~~4*i||abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, iwill nonetheless ensure that all conditions of
Part ||ofthe permit are met Vothe project ataUtinnes.
' hereby request coverage under 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 as an individual it
Name of Project:
Legally Responsible Organizational Entity:
Legally Responsible Person:
Title of Legally Responsible Person: "7 h, e
*Signature: V/1
*Print Name and Title ofSigned if Authorized
Individua/Diffemfrom Pennittee
1
Phone Number: , ~ ~)4,.
IMPORTANT NOTE: Thisfbrmmust besigned bvo responsible corporate officer that owns oroperates the
construction activity, such as o president, secretary, treasurer, orvice president, or manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, SectionB, Item (6)ofthe N[GD0O00permit.