HomeMy WebLinkAboutNCC216365_NOI Signed Certification_20211124NCGO1 Notice of Intent (N01) Certification Form
Directions*
Print this fonn complete, scan and upkmdtothe m�otnonicN0i
Then maUtheor\Qina\formtnthe' CDEKALR'StormwaterProgram kw�h$1ODcheck ifpoy�gbychec�at:
' Division ofEnergy, Mineral & Land Resources StormwmterProgram
512N.Salisbury Street, 6~Floor (office 64OK)
l61ZMail Service Center
Raleigh, NC27699'1612
DONOT 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 CFR122.221
Per W[General Statute 149-215.6B(i),any person who knowingly makes any false statement, representation, or
��
cerbf�o�on/nany opp&zx�on,reoontreportp��fi
led «/noe/
Article ororule implementing this Article ... shall beguilty ofoClass 2nniswhich may include ufine not tu
exceed ten thousand dollars ($10,000). ,
Under penalty mflaw, | certify that (check all boxes toindicate your :
—/ \amthepenmnnesponsi�efortheconstnucbactivities therequ\rema�suf1hb
"~ ermm� mndforanydcriminal permit.
p,
—/ Thein�orma�innsubmhtedinth\sW0|b,tothebeutofmyknowhedQeandbei���ue,accu,mte,mndcomp\ete
�y who orthose peoonsdireu±�responsible for
baoedon�yinquiryofthepersmnorpersmnsw ,
gathering the information.
-~/ | will abide &yall conditions mfthe and the approved Erosion and Sediment Control
Plan.
/ \ftheap�rove�Ero�ionan��ediment[ontom|P\anisnotmmmp|ientm/bhpa�U Stormvvm1erPo||ution 8 of the
�� �vvU|nonethe|essensurethotaUmond�\onsotPa� m
9reven��onP|an)ofthe NcG010000 General permit,
permit are met onthe project atall times.
/ an�understand�ha�coveraQeunder this
6 �he
�herebyrequestcwvera8eun er ..�__��-- - _
- --------�� d {� b| � thesam� m�nnerasmn
^- �'rmit' 3|'onstitutet eparmitrequi/emen�sforthedischarBe(y)an isen rcea � n
individual permit.
Name of P
ect (must match Ala'
L
�M"/uj6
Specific Lot Numbers (must match Alb): L4- 5
Legally Responsible Organizational Entity (must match Bl):
Legally Responsible Person (must match B2 & 83): 0 V"J
Title of Legally Responsible Person (must match B3b):
Name & Title ofSigned ifAuthorized Individual
LegallyDiffers from Responsible Person:
Phone Number: q l106
PenmnorAuthorized Individual
�/�n�����o��������u�m���em����
��/m�w'�' �ot�v�m���������/����
such uoopny�en�sooru/rK�yosum�cvv�epxs�en�orumanager
Item (Vo/the NC6010000permit.