NCC213205_NOI Signed Certification_20210527

NCGO1 Notice of Intent (NOT) 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
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,h Floor (Office 640K)
V 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
check) at:
Per NC General statute 143-215.69 (i), any person who knowingly makes ony 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 sholl be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under nalty of law, I certify that (check all boxes to indicate your agreement): 1
I am the person responsible for the construction activities of this project, for satisfying the req iremerits of this
perrnit, and for any civil or criminal penalties incurred due to violations of this permit.
1
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurat' , and complete
based on my inquiry of the person or persons who manage the system, or those persons direc+�ly responsible for
j� gathering the information.
U I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and 1ediment Control
Plan.
JG if the approved Erosion and Sediment Control Plan is not compliant with Part li (Stormwater P flution
Prevention Plan). of the NCGO10000 General Permit l 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 NCG01QQ General Permit and understand that coveragQ under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the salme manner as an
;-444,4-1 nnr if -
Name of Project (must match Al a): /rij 1 6/0 Ile
Specific Lot Numbers (must match Alb): - 2
Legally Responsible Organizational Entity (must match B1): t t' d lGc�i
ct2 Elo
Legally Responsible Person (must match B2 & B3): zOh Gr^G41S+��
'title of Legally Responsible Person (must match B3b): A-9'l4f74 /+
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number- �>3 ~ Q 4Q — 7d12 1P.
-
Signatkde of all espo a Pe on or Author zed Individual Da
te
IMPORTANT NOTE.- This form must be signed by c responsible corporate officer that owns or operates the con
'truction activity,
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordance with
art 1V, Section S,
Item (6) of the NCG010000 permit.
C/C