NCC215103_NOI Signed Certification_20210914

NCG01 Notice of Intent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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 StonnwmterProgram
512N.Salisbury Street, 5mFloor (Office 64Ok)
1612Mail Service Center
Raleigh, NC%7699 1622
410 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEI
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (J), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementingthis Article ... shall beguilty ofoClass 2misdemeanor which may
include o/nenot toexceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
X1 |amnthe person responsible for the construction activities ufthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
DC The information submitted inthis NO|is,tothe best ofmyknowledge 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 bvall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
X |fthe approved Erosion and Sediment Control Plan isnot compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit / will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
� | 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 Runway 23R|LBInfrastructure
LegallyMarine Cherry
Legally Responsible P AnthonyFerence
Title f LegallyD9puty Facilities Director By direction of the Commanding Officer
*Signature: 6, -a r�_�4_, Date: 0 ? 0
*Print Name and Title o�Sjign d if uthorized
—Individual Differs from Permittee:
Phone Number: 252-466-3807
*IMPORTA0TNO7E. This form must besigned bvoresponsible corporate officer that owns oroperates the
construction activity, such asopresident, secretary, treasurer, mvice president, oromanager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section fLItem (6)ofthe NC6O0000permit.