NCC201970_NOI Signed Certification_20200515

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 StonnwoterProgram
512N.Salisbury Street, 6mFloor (Office 64OK)
l6l2Mail 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 Statute243-225.6B (i), any person who knowingly makes mnyfolse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required tobemaintained
under this Article ororule implementing this Article ... shall beguilty oƒoClass 2misdemeanor which may
include oftnenot toexceed ten thousand dollars /$20,000/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
O� 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.
C� 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.
Ex] | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
Q� 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 uf
Part Uofthe permit are met onthe project atall times.
Ox | hereby request coverage under the NCG010000 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 asanindividual permit.
Name ofProject: CybordynaBorrow Pit
Legally
Title of Legally
*Signature: Date: APM4L—:a�
*Print Name and Title of S n difAutho
,6
Phone Number: [phone]
*IMPORTANTNOTE.This form must be signed byoresponsible corporate officer that owns moperates the
construction activity, such as a president, secretary, treasurer, or vice president, or a 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 (6) of the NCGO10000pamit.