NCC215275_NOI Signed Certification_20210927

NCGO1 Notice of Intent (N01) Certification Form
Directions6
:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying b y check) at:
Division of Energy, Mineral k I ;ind Resources qtnrmxA/;;tpr Program
S12 N. Sali
sbury Street, 6t, Floor (Offi
1612 Mail Service Center
Raleigh., NC 27699-1612
ce 640K) v
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 12122]
Per NC General Statute 143-215-6B (i), any person who knowingly makes anyfalse statement,, representation, or
certification in any application, record, r
Article or a rule implementing this Artict
exceed ten thousand dollars ($10,000).
eport, plan, or other documentfiled or required to be maintained under this
Plqw ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
Under penalty of law, I certify that (check all boxes to indicate your agreement):
C�I am the person responsible for the constructi
permit, and for any civil or criminal penalties i
Er The information submitted in this N01 is, to t
on activities of this project, for satisfying
ncurred due to violations of this permit.
the requirements of this
he 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 respon
gathering the information.
C7� I will abide by all conditions of the NCG010000 General Pitermand the approved Erosion and Sediment Control
Plan.
Bible for
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.,
L�J I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala):
Specific Lot Numbers (must match Alb),,40
Legally Responsible Organizational Entity (must match Bl). Si rXA
Legally Responsible Person (must match 82 & 83): �C��
Title of Legally Responsible Person (must match 83b): D C�7��v"�'-�.-�c' O� ����"r�C.Sv�'�tnrN�
T
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: � 17y� C\`z-),,a4c�j�.�Qy
'gal
Signature of Legally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such os a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCGO10000 permit.
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