NCC212760_NOI Signed Certification_20210511

?,JCG01 Notice of Intent Certification Form
a re,C tioiis:
Print this form, complete, scan and upload to the electronic NOL
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
Per NC General Statute 143-215.68 (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):
X 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.
X The information submitted in this NO] 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.
® 1 will abide by all conditions of the f°1CGQ10QGQ Generai Pe+ nit and the approved Erosion and
Sediment Control Plan.
X If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NOGO 10-000 <3e.fi ra'. 3 j�rM, , I will nonetheless ensure that all conditions of
Part ll of the permit are met on the project at ail times.
X I hereby request coverage under the ` v...m... ' u _ .xand 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 Project: C-12 Hangar Replacement (P728)
Legally Responsible Organizational Entity: MCB Cam L!Jeune
Legally Responsible Person: Neal Paul
Title of Legally Responsible Person: Depuly Public Works Officer
nature:
*Print Name and Title of Signed if Nthorized
Individual Differs from Permittee. Talia Prende ast PWD Civil Engineer
Phone Number: (91 G) 451-3238 ext_ 3242
Date:
* 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 NCGO10O00 permit.
For more information an signatory requirements, see Part IV, Section $, Item (6) of the NCGO10000 permit.