NCC214218_NOI Signed Certification_20210721

NCG01 Notice of Intent (N0I) 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 check) at-
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6v, Floor(Office 640K)
1612 Mail Service Center
Raleigh. NC 27699-1612
L?R PAYMEN'i J(" i it_ u!.�r;,.: s LIB:;i!ON HAS BEET a :!CCE i s ❑ AS COMPLi i
- - - 'GNATURE(NOT DIGITAL) [40 CFR 122.22i
NC General Statute 143-215.6E(i), any person who knowingly makes any folsestaternent, representation, or
-ri{cation in any application, record, report plan, or other document filed or required to be maintained under this
or o rule implementing this Article . . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
ten thousand dollars (510,000).
L: penalty of law, I certify that (check all boxes to indicate your agreement):
; am me 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 permi:-
The information submitted in this NO[ is, to the best of my knowledge and belief,true, accurate, and complete
oased on my inquiry of the person or persons who manage the system, or those persons directly responsible;c-
gathering the information..
XI will aoide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Contra:
Plar..
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Pr='Vertition Plan) of the ,vCC-010000 Genera Perms-, I will nonetheless ensure that all conditions of Part 11 of t1,
aerrr;it are net on the project at all times.
I he•eby request coverage under the NCG01000Q Genera! Permit and understand that coverage under this
oer:mir vAli constitute the permit requirements for the discharge(s) and is enforceable in the same manner 3j-:r
individual permit.
-ime of Project {mustmatchAIa): t r �-- —
n r Y _�C t C�F7- r� A\.4
�necific Lot Numbers (must match A1b):
Legally Responsible Organizational Entity(must match B gt;}
Legally Responsible Person (must match S2& 83): j�U 1` j ; ` �t z•
itle of Legally Responsible Person (must match 63b).-
",lame &Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number:
Signature of Legally e ponsible Person or Authorized Individual ❑a e
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that awns or operates the construction
;Lich as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section d
,errs 16)of the NCG010000 permit.