NCC214653_NOI Signed Certification_20210819

IVCG01 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload t4 the electronic NOI.
Thin, maji the original form to the NC DE�l I., R Stormanrater Program (with 5100 check if paying by check) at:
Division of Energy, Mineral & Laid resources 5iormvrrater Program
512 N. Salisbury Street, &F Fluor (Office 540K)
1512 Mai! Service Center
Raleigh, NC 27699-1612
DO NET
MAIL
THIS
FORM
OR
PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED A,5 COMPLETE.
THE FORM
YOU
MAIL
MUST
BE
COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CAR 122,221
Per NC General Statute 143-215,6B (i), ❑ny person who knowingfy makes orgy falsestotement, representation,, or
tertificatran in any opplicativn, rec ord, report, plan, or other document filed or required to be main to] ned under this
Article or a rule imr�lementing �fais Article... ... shall be guilty of a Class � misdemeanor which may ir�clude a fine nvt to
excQed ten thousond dollars ($10,000)4:
Under penalty of law, I certify that (check all'boxes tv l"ndikate your agreement):
20""' 1 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 dire to violations of this hermit.
rvel"P" ti
The information submitted i this 1 r , to the best of my knowledge and belief, true, accurate, aril complete
based on my inquiry of the person or persons who manage the system, or those persons direct!y responsible for
gatherings he i nfo r-ma 0on.
L
L001
1 lit abide by all conditions of the NCG010000 Gerie!-A r rn i and the approved Erosion and Sediment Control
Plan.
the a r d E r ion and d i rat Control Plan
is not compliant it h Part It (Stormwater Pollution
Prevention Plan) of the
CGO10000 General Pere
permit are met an the project at all tirne5.
I will nonetheless ensure that all conditions of Fart 11 of the
I hereby request coverage under the 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 (Mu5t motch Ala):
�_.....,..�,r
Specific Lot Numbers (must match AIb):
AC 04 � cr- kL fz'
217- 40 ifs_
._. ___ —r! -1Y. . — .__---__ T—Rv zT.l woof__._._—_ ..1�iLTa•1aa
Legally Responsible Organizational Entity (must match
... .. ._ rx• r :: ,._.. --- --+ram-�� ��
Legally Responsible Person (must match K Lek, r
Title of Legally Responsible Person (must match B: LZ
—
Name & Title of Signed if Authorized Individual
r
iffersfrom Legally Res.ponsible Persow,
Phone Number: 0
Signature of Legally Res pan l
won or Authorized Individual
Date
I.M T NOTE.- This form must be signed by a responsible corporate officer shot owns or operates the construction activity,
such as s Prey ide n t# s ecreto rt'.. tre asu rer, o r vice p re i de r, o r a m a no y er th o t is o u th p rued in s ccordanc e wi th Part I, S ec t ion B.,
Item (6) of the NCG010000 permit.