NCC221500_NOI Signed Certification_20220418

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StormwaterProgram
512 N. Salisbury Street, 61h Floor (Office 640K)
DO NOT 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 C-rR 122121
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 documentfiled 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 /$2(l000/.
M |amthe person responsible for the construction activities ofthis project, for satisfying the requirements ofthis
[� 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.
[7l | will abide byall conditions ufthe NCG010000 General Permit and the approved Erosion and Sediment Control
[77 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart Uofthe
permit are met on the project at all times.
[/] | 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.
Project Name (must match Ala): FiberQA3NL Expansion
SoecificLot Numbers (must match A2b):
Permittee (must match Bl): Fiber Composites, LLC
Legally Responsible Person (must match B2 & B3): Mike Miller
Title of Legally Responsible Person (must match B3b): Fiber Composites, LLC Controller
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number: 704-46�/-' ~1��
Signature Of Legally Resp-onsible Person or Authorized Individual
IMPORTANTNOTE: This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such csopresident, secretary, treasurer, orvice president, u/amanager that isauthorized /naccordance with Part IV, Section f\
Item (6)ufthe NCG0 0000pennit.