NCC202912_NOI Signed Certification_20200713

NCG01 Notice of Intent (NOI) Certification Form
Directions:
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" 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 Statute 143-215.6E (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 o fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
it 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
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 by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
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 Proiect: eNOI 27983, NCC—DUPLI-2020—Town of Warsaw Contract Number 42
Legally Responsible Organizational Entity: TOWN OF WARSAW
Legally Responsible Person: A.J. Connors
Title of Legally Responsible Person: Mayor1.
*Signature:
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: 910--293-7814
Date: 7/10/2020
* 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 B, Item (6) of the NC6010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

7/8/2020 Resume Submission
Construction Stormwater: Notice of Intent (NOI)
�.: National Pollutant Discharge Elimination System(NPDES)application for coverage under North Carolina's
General Permit NCGO10000: STORMWATER DISCHARGES associated with construction activities(or
NCG250000)
NORTH CAROLINA
EnvironmentalQUality A. Project Information B. Permittee Information C.Site Contact information D. E&SC Plan
E.Certification
North Carolina General Statute 143-215.613 (i) provides that:
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;or who knowingly makes a false statement of
a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly renders inaccurate
any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission
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:
* Q 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.
* Q 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.
* Q I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* Q I 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 as an
individual permit.
Specify if you are:* OO The Responsible Person named on this Notice of Intent
Q Authorized Responsible Person*
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
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 B, Item (6) of the NCG010000 General Permit. For more information
on signatory requirements, see Part IV, Section B, Item (6) of that permit.
https://edoes.deq.ne.gov/Forms/form/resume/241/65539 1/2

7/8/2020 Resume Submission
Signature�` x
Aj Coolva
Type Name* A. J. Connors
Title* Mayor
Organization* Legally Responsible Entity
Town of Warsaw
Date* Date captured on form submission
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