NCC221549_NOI Signed Certification_20220421

NCGO1 Notice of Intent (NN01) Certification Form
Directions:
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, 6th 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 COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122922]
Per NC General Statute 143-215,, 6B
certification
any person who knowingly makes anyf alse statement, representation,representation,or
licatiaonl record, report, plan., or other documentfiled or required to be maintained under this
Article or a rule implementing this Article ...shall be guilty oT a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
in any app
Under penalty of law, I certify that (check all boxes to indicate your agreement):
L\\J I am the person r
4W
1 permit, and fo
esponsible for
Im d
the construction activities of this project,, for satisfying the requirements of this
r any civil o r c r i i na
U The information submitted
I Penalties incurred due to violations of this permit.
in this NOI is, to t
based on my inquiry of the person o
� gathering the information.
r persons who manage the system
he best of my knowledge and belief, true, accurate, and complete
irectly responsible for
or those persons d
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 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 NCG010000 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).a
Specific Lot Numbers (must match Alb).
Permittee (must match Bl):
Legally Responsible Person (must match B2 & B3):
Ll
LaN
Title of Legally Responsible Person (must match B3b): Owl qe\r
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: V�''�b�
Sign (tture of Legally Responsible Person or Authorized Individual
ai �0
Date
* IMPORTANTNO : 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 B,
Item 6) of
the NCGO1 0000 permit.(