NCC220323_NOI Signed Certification_20220118

NCG01 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic N01.
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, 6t, Floor (Office 640K)
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Per NC General Statute 143-215.6B (i), 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 ofine not to
exceed ten thousand dollars ($10, 000),
✓ 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 peIII-ni".
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 systern, or those persons directly responsible TO,'
gathering the information.
I will abide by all conditions of the NCGO10000 General PI and the approved Erosion and Sedirnent Control
Plan.
If the approved Erosion and Sedin-)ent Control Plan is not compliant with Part 11 (Stormwater Poilution
Prevention Plan) of the NCG010000 Genc-al Permit, I will nonetheless ensure: that ail conditions of 1 11 of the
permit are met on the project at all times.
ED I hereby renuest coverage tinder the NCG010000 General Per and understand i hat coverage Uncle r this
perr-nit will constitute the Permit requirements for the discharge(s) and is enforceable in the same m2tnner as sn
individual permit,
,Matthews L -,n
Specific Lot Numbers (must match Alb): Lot No.'s 1-226
?ermittee (must match B1): Matthews Landing Development LLC
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Title of Legally Responsible Person (must match 83b): Agent
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Signature of Legally Responsible Person or Authorized Individual Date
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns 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, 8,
item (6) of the NCGO1 0000 permit.