NCC192246_NOI Signed Certification_20191009

Fill Pill III III
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 0 Floor
1G12 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68 (i), any person who knowingly makes any 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 a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (checl< all boxes to indicate your agreement);
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.
The information submitted in this NOI is, to the best of my I<nowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
1 directly responsible for gathering the information.
1!�'f I will abide by all conditions of the NCGO10000 General Permit and the approved Erasion and
/ Sediment Control Plan.
fA 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
Part II of the permit are met on the project at all times.
l I 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 permit.
Name of Project: 4G ke CeA'
Legally Responsible Organizational Entity: ` I t� C—k-" li
*Legally Responsible Person: Dep ZO-A Ira
Title of Legally Responsible Person;
Signature;
Date; 1
* 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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.

DOCUMENT NAME:
Ake C�tirs
This is to advise the Mayor or City Manager that the expenditures in the attached document have .
been fully provided for in the current annual operating budget or the current capital budget.
N/A
Budget/Resear irector'
Date
This document has been pre -audited in the manner required by the Local Government Budget and
Fiscal Control Act.
N/A
Finance Directo
Date
This document has been reviewed by the Risk Management Department and the appropriate
insurance coverage has been provided.
N/A
Risk Managem erector
Date
This is to advise the Mayor or City Manager that the attached document has been reviewed by the
City Attorney's Office and is ready for signature by the City.
City Attorney
Date
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