NCC215261_NOI Signed Certification_20210924

NCGO1 Notice of Intent (NO[) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division ofEnergy, Mineral & Land Resources StormwaterProgram
512N.Salisbury Street, 6~F|oor(Office 64UK)
1612Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
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Per NCGeneral Statute 143-215.6B0tany person who makes myfabestatement, representation, or
certification inany application, record, report, plan, or other documentfiled or required to bemaintained under this
Article mrorule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$18OOU>.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
� �
oo I am the person responsible for the construction activities of this project, for satisfying the requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
�
s� The information submitted in this NOI is, to the best of my knowledge 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 byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
Ifthe 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 ofPart ||ofthe
permit are met onthe project atall 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 Project (must match Ala): -17cl 11 SVi j25 Lcod t nq - Je-mican A-kon-w-
Specific Lot Numbers (must match Alb): OJLJ n�,i 2-5
Legally Responsible Organizational Entity (must match 81): SC�tv-VJM :11y) C
Legally Responsible Person (must match B2 & 83): <A M -:77 R-e" t &Itt)
Title of Legally Responsible Person (must match 83b): civaA-) A-
Nanle&Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number: 110-360-,82,2(o
Signature ofLega
ble Person or Authorized Individual
IMPORTANTNOTE., This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such asopresident, secretary, treasurer, mvice president, momanager that bauthorized inaccordance with Part IV, Section 8,