NCC200493_NOI Signed Certification_20200210

Directimm
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 Resources Stormwater Program
512 N. Salisbury Street, 6 th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Sta/ute143-215,6B(I), any person who knowingly makes anyfalse statement, representation,
or certification in any application,record, report,plan, or other documentfiled or required tobemaintained
under this Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may
include o fine not to exceed ten thousand dollars($20,O0U).
Under penalty of law, I certify that(check 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 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.
|will abide bv all conditions nfthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
1�r if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ofthe NCG010000 General Permit |will nonetheless ensure that all conditions of
Part||of the permit are met on the project ut all times.
| hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements forthe discharge(s)and is enforceable in the
same manner axan individual permit.
.
-Legally Responsible Organizational Entity: 1­0i/~-*Signature: Date:
*Print-Legally Responsible Person: jFIWAD V-F-LJ-Y
Title of Legally Responsiy4e Person: 'DIU
/f Authorized
-Phone Number:Individual Differs from Permittee: A)/77--
xf/ 4
*/&YPORTA/VT0OTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such osopresident, secretary, treasurer, or vice president, oro manager that is
authorized in accordance with Part IV,Section B, Item(6)of the NCGO10000 permit,
For more information on signatory requirements,see Part IV,Section B, Item kJof the NCG010U00permit.