NCC216444_NOI Signed Certification_20211119

NCG01 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 DLMLR Stormwater Program (with $100 check if paying,
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,1, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [4
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, represents
certification in any application, record, report, plan, or other document filed or required to be maintained
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include +
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
at:
'LETS.
122.221
ion, or
,ruder this
fine not to
i am the person responsible for the construction activities of this project, for satisfying the requir ments 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.
will abide by all conditions of the 1VCG010000 General Permit and the approved Erosion and Se invent Control
Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Polk tion
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions f Part II of the
permit are met on the project at all times.
hereby request coverage under the NCG-01.0000 Geneml F'eri fit and understand that coverage nder this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the sam manner as an
individual permit.
Name of Project (must match Ala):
q
Specific Lot Numbers (must match Alb): 1
Legally Responsible Organizational Entity (must match Bl): S�r�?�r�i� �wcv�L^/ �tt; � L-
Legally Responsible Person (must match B2 & B3): 12 /� J��r��—Y] E
Title of Legally Responsible Person (must match B3b): /J✓f
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: % L S
u of egall esponsible
erson or Authorized Individual
c,z1
Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that awns or operates the constriction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Pa IV, Section B,
Item (6) of the NCG010000 permit.