NCC210144_NOI Signed Certification_20210127

NCG01 Notice of Intent (NOI) Certification �orm
Directions:
Print this form, complete, scan and upload to the electronic OI.
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=h 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 143-215.6B (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 (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for sati
permit, and for any civil or criminal penalties incurred due to violations of this pe
The information submitted in this NOI is, to the best of my knowledge and belief,
based on my inquiry of the person or persons who manage the system, or those K
gathering the information.
k I will abide by all conditions of the NCG010000 General Permit and the approved
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (S
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure tha
permit are met on the project at all times.
hereby request coverage under the NCG010000 General Permit and understand
permit will constitute the permit requirements for the discharge(s) and is enforce
individual permit.
Name of P ject�((must match Ala)iA
�` �? t n 1�%cL;4 e4wJ
Legally Respon ible Organizational Entity (must match 61)
T �'rG1u� M (I I
Legally esponsible Person (must match B2 & B3)
i ivee�oT Legaiiy Responsible Person (must match B3b)
*Signature
0(
Date
rrint Name and Title of Signed if Authorized Individual Differs from Legally
Phone Number A
la. s
IMPORTANTNOTE, This form must be signed by a responsible LJ ,-"t officer p ff t at owns or oK
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in ac
Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV,
NCG010000 permit.
ying the requirements of this
mit.
true, accurate, and complete
ersons directly responsible for
ion and Sediment Control
Drmwater Pollution
all conditions of Part II of the
hat coverage under this
ble in the same manner as an
Person
� 0C
$l0_
-es the construction activity,
once with Part IV, Section B,
`ion B, Item (6) of the