NCC214499_NOI Signed Certification_20210809

NCGOI Notice of Intent (NOI) 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 StornnwvaterProgram
S12N.Salisbury Street,6~Floor(Office 64DK)
_ 1612 Mail Service Center _
- Raleigh, NC27G99-1612 -
0O NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM �~mLm�mw�^BE �nmrH A �� ~' ��� ���;��m ���������
.
—_ -_— COMPLETED_.. ORIGINAL�—.--. . SIGNATURE(NOT. . .
Per NC General Statute 143-22Si68(i), any person who knowingly makes onyfadsestatement,representation,or
certification in any application,record,report,plan, or other documentfiled or required tmbe 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($1LlDOO)'
Under ena|tyof law, |certify that(check eNboxes tm indicate your mQreemment):
E� |anmthepemonresponsib|efortheconstrucLionactivitiesofthixproject,forsatisfyinQthenequirenoentonfthis
permit,and for any civil orcriminal penalties incurred due to violations of this permit.
Cl/The information submit dinthisNOIis,tothebesiofmyknovv|ed8eandbe|ief,true,accurate,andconnp|ete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
athering the information.
3 |xvi||abidebya||conditionsofthe NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
[] If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ofthe NCGO10000 General Permit, |will nonetheless ensure that all conditions of Part||ofthe
rmnit are met on the project at all times.
[g/ | herebyrequestcoveraOeunderthe NCGO10000 General Permit 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.
Name of Project(must match Ala):
Specific Lot Numbers(must match Alb):
- Legally Responsible Organizational Entity(must match Bl): OkKL�
Legally Responsible Person(must match B2& B3):
Title of Legally Responsible Person(must match B3b):
Name&Title of Signed ifAuthorized Individual
Differs from Legally Responsible Person:
Signature of LegWly Responsible Person or Authorized Individual Date
* IMpORT4my0OTE. This form must be signed byo responsible corporate q/ficsrthat owns nr operates the construction activity,
such oso president,secretary,. treasurer,or vice president,oro manager that is authorized hn accordance with Part IV,Section 8'
Item(6)py the NCGO10000permit.