NCC213384_NOI Signed Certification_20210604

NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload 10the electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Lend Resources StonnvvaterProgram
512 N. Salisbury Street, 6'^Floor (Office 648K)
1G12Mail Service Center
Raleigh, NC27699'I6I2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPI-, -- 4
Per NCGeneral Statute 243-215,68(i), anyperson who knowingly makes anyfabestatement, representation, or
certification in any application, record, report, plan, orother documentfiledor required to be maintained under this
Article ororole implementing this Article shall be guilty of a Class 2 misdemeanor which may include afine not to
exceed ten thousand dollars ($10, 000).
Under penalty n/law, i certify that (check all boxes to indicate your mQreennent):
M� 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.
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 byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) vfthe | will nonetheless ensure that all conditions ofPart Uofthe
permit are met onthe project atall times,
/ hereby request coverage under the and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner axan
individual permit.
Name of Project (must match Ala): C r-oss C� C�qm'o V, To �P-,n � o vv) -eg
Legally Responsible Organizational Entity (must match Bl): 'T 1 41' 0y) cm
Title of Legally Responsible Person (must match B3b): C
Name & Title of Signed if Authorized Individual
Differs from Legally
Signa,eifre of Legally R'�spo
Person or Authorized Individual
IMPORTA0rNuTE. This form must besigned byoresponsible corporate officer that owns oroperates the construction activity,
such osopresident, secretary, treasurer, or vice president, ora manager that is authorized in accordance with Part IV, Section 8,