NCC215599_FRO Submitted CHECK DOCUMENT_20211011

Construction Stormwater otice o
Intent (No!)
National Pollutant discharge Elimination System (NPDES) application for coverage
under North Carolina's General Permit NCG010000: STORMWATi=.R t)ISC:EIARI;G_
associated with construction activities (or NCG200000)
f A. Project Information 1 B. Permittee Information C
{ D. E&SC Plan E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report,
plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who
knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; '±
or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required
to be operated or maintained under this Article or rules of the Commission implementing this Article shall be guilty of a
Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).'
Under penalty of law, I certify that:
B 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 due to violations of this permit.
Tho information submitted in this NOI is, to the best ofmy
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.
I will abide by all conditions of the NCGO10000Gener�i Permit and
the approved Erosion and Sediment Control Plan.
If the Erosion and Sediment Control Plan approved by jthe
delegated program is not compliant with Part it (StormI�ater
Pollution Prevention Plan) of the NCGO10000 General Permit, I will
nonetheless ensure that all conditions of Part Il of the �ermit are
met on the project at all times.
r-ttrs:/)edoCS. dGq.nc.gnv/For ms/NCGa1 -NO I
I
1
i
10,15/21,, 3'_2 PM
Page 1 of 9

4
Zlhereby request coverage under the NCG010000 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.
Specify it you O T e Legally Responsible Person named on this Notice',of Intent
are: �thorized Responsible Person* (signing on behalf of lie all
9 y
Responsible Person named in Part B)
i
Important: The person who electronically signs this Certification above must be the same person who
signs the NOI Certification Form. If that person is signing on behalf of the Permittee, that individual
must be an authorized responsible person within the same organization as the Permittee. *An If
authorized individual is a responsible corporate officer who owns or operates the construction activi,
such as a president, secretary, treasurer, or vice president, or a manager that i§ authorized in
accordance with Part IV, Section B, Item (6) of the NCGO1 0000 General Permit i For more
information on signatory requirepero, see P ection B, Item (6) of that permit.
Signature gn
Type Name ���n �f��oot✓S +cr
Title
Organization Legally Responsible Entity
Date's Date captured on form submission
Previous
I'm not a robot
reCAPTCHA
Privacy - Terms
Submit Save as Draft
.. - ._ docsci�q.n� �r.•:r�c.rasj�i ;'3D9-?JCi 4GiSi�i, 3 - 2=-