NCC213804_NOI Signed Certification_20210625

NCG01 Notice of Intent (N01) Certification Form
Directions:
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 checks at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street,, 6th Floor (Office 640K)
P° 1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT
MAIL
THIS
FORM
OR
PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM
YOU
MAIL
MUST
BE
COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL)
[40 CFR 122121
Per NC General Statute 143w215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, retard, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty o, f a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under p naltv of haw, I certify that (check all boxes to indicate your agreement):
� are the person responsible for the construction activities of this project, for satisfying the requirements of this
permft, and for any civil or criminal penaltiesincurred due to violations of this permit,
The information submitted in this N01 is, to the best of mkt knowledge and belief, true, accurate, and complete
based on rny inquiry of the person or persons who manage the system, or those persons directly responsible for
ga Bring theinformation.
I will abide by all conditions of the n�rrni r�t�r�r� renera� Permit and tie approved Erosion and Sediment Control
Phan.
If the approved Erosion and Sediment Control Plan is not compliant with Part it (Stormwater Pollutibn
Prevent'l'on Plan) of the NCG010000 General Permit., I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times,.
I hereby request coverage under the NFG(','1 n'-)0A �erpr�; Pinrm-
Ht and 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.
Larne of Project fmust match Ala):
I
Soecific Lot Numbers (must matey AIM:
At..V14�'
legally Responsible organizational Entity (must match B
Legally Responsible Person (must match 82 & B3):
Title of Legally Responsible Person (must match 83b).
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Dumber: �� f `� fz/� i'�
Signature of Legaljj7RespopAle Person or Authorized Individual
L,
23
If Date
* IMPOR TA NT NOTE:?
This form
must be signed by a responsible
corporate officer that owns or operates th e construction activity,
such as a president,
secretary,
treasurer, or vice president, or a
manager that is authorized in accordance with Part IV, Section B.