NCC211776_NOI Signed Certification_20210325

111MICGOI Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Ihen, 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, 6,1, 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 ► S COMPLETE
Per NC General Statute 143-215.6E (i), any person who knowingly makes any fafse 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 tern thousand dollars ($10, 000)-
Under penalty of law, I certify that (check all loxes to indicate your agreement):
❑✓ I am the person responsible for the construction activities of this protect, for satisfying the requirements of tl�is
',.-permit, and for any civil or criminal penalties incurred due to violations of this permit.
❑ The information submitted in this N01 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.
D`_l will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan_
❑ 1f the approved Erosion and Sediment Control Plan is not compliant with Part It (Stormwater Pollution
Prevention Plan) of the NCGOJ-0000 General Permit, l will nonetheless ensure that all conditions of Part It of the
permit are met on the protect at all times_
I hereby request coverage under the KGO10000 Genera! Permit and understand that coverage ender this
permit will constitute the permit requirements for the discharge{s] and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): � ` 1 G t�(.r--r it k rU �} Vj
Specific Lot plumbers (gust match Alb): i _
Legally Responsible Organizational Entity (must match 31): Uj.4t 12-S
Legally Responsible Person (must match B2 & B3): 7j;'M C- L Ei2
Title of Legally Responsible Person (must match B3b): I'►AE fv\►V,F
Name & T'itle of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number:
a i"o L g iyResporfsib-Ie4�e�son or Authorized lndWdual bate
* IA600?TANT NOTE: This form must be signed by o 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 P/, Section B,
item (5) of the NC6010005 permit.