NCC220203_NOI Signed Certification_20220111

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Directions:
.Print this form, complete, scan and upload to the electronic NOL
Them, 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, 6th Floor (Office 640K)
1.612 Mail Service Center
Raleigh, NC 27699-1612.
Per NC General Statute 143-215.68 fl), 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. shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars {$10,000j.
Under penalty of law, I certify. that (check all boxes to indicate your agreement):
r 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 N01 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 personsdirectly responsible for
gathering the information.
f: I will abide by all conditions of the NCGO10000 General. Permit and the approved Erosion and Sediment Control
Plan.
W/ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention flan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
[ I hereby request coverage under the NC 01.0000 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):
onsible Organizational Entity (must match Bl ):
Legally Responsible Person (must match 82 & 83):
Title of Legally Responsible Person (must match 8.3b): r I`. #1..Q 1A
Name & Title of Signed if Authorized. Individual
Differs from Legally Responsible Parson:
Phone Number:
Signature of Legally Responsible Person or Authorized individual
Gate
LC— . .
* IMPORTANT NOTE. Thisform must be signed by a responsible corporate officer Mot awns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part. IV, Section B,
Item (6) of the NC'G01.0000 permit.