NCC201383_NOI Signed Certification_20200408

NCG01 Notice of Intent (NOU) 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 ifpoying by check) at:
Division ofEnergy, Mineral 8'Land Resources StormxvaterProgram
512N.Salisbury Street, 6mFloor (Office 64OK)
1612 Mail Service Center
Raleigh, NCI769S-1612
DO NOT MAIL THUS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation,
or certification inany application, record, report, plan, orother documentƒiledor required tobemaintained
under this Article urorule implementing this Article. .. shall beguilty ofoClass 2misdemeanor which may
include ofine not to exceed ten thousand dollars ($20,000
Under penalty oflaw, ! certify that (check all boxes 10indicate your a0reemend:
Iamthe person responsible for the construction activities ofthis project, for satisfying the
requirements ofthis permit, and for any civil orcriminal penalties incurred due toviolations nfthis
permit.
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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,
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�| | will abide bxall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
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�| If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit,|will nonetheless ensure that all conditions of
Part ||ofthe permit are met unthe project atall times.
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�| | 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 aoanindividual permit.
Name ofProject: L8rkhaVen Electrical Substation
Legally Responsible Person: David Gross
Title of Legally Responsible Person: Vice President - Enqineerin.q Operations
*Signature: "r Date:
*Print Name and Title ' edifAutho/ized
Individual Differs from Permittee:
Phone Number: 145
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such asopresident, secretary, treasurer, or vice president, oromanager that is
authorized inaccordance with Part IV, Section B, Item (6) of theNCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.