NCC216300_NOI Signed Certification_20211112

NCGO1 Notice of Intent (NOI) 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 Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27690-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [mil CFR 122.221
NC General Statute 143-21.5.6E (i), any person who knowingly makes any false statement, representation, or
ification in any application, record, report, plan, nor other document filed or required to be maintained under this
LiC or a rule iFrnptCmentIng tl!;s Af Ll[ le . . . .slim, F�FG ilcy of a UaSS c irri`id `i curFir r'r'lirLii rn y it rcliidc a ffrl2 irvt tCl
-ed ten thousand dollars ($10,000).
ler enalty of law, I certify that (check all boxes to indicate your agreement):
I 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.
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.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
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.
LJJ 1 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): V
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity (must match B1): V-y (A yX V
Legally Responsible Person (must match B2 & B3): G7 (�,yix, Al) zr\
I
Title of Legally Responsible Person (must match B3b): V'C'57, se'/VA 0 VJ y-'Z�
Name & Title of Signed if Authorized individual
Differs from Legally Responsible Person:
Phone Number: G O_ l- I IS 66 S
i - /�On� .r Iki_In