NCC221564_NOI Signed Certification_20220504

NCGO1 Notice of Intent (NOI) Certification Form
Directions;
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC OEMLR Stormwater Program (with $100 check of pay►ng by rherk) at:
Division of Lnerpy, Minetal & Land ReSollfCeS 5tormw er Program
512 N. Salisbury Street, 61, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 276941fi12
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED W1TH AN ORIGINAL SIGNATURE (NOT WGITAL) 140 CFR 122.221
Per NC General Statute 143-215.60 (i), any person who knowirrgly makes any false statcmenL rcprcxe ntation, or .
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule impleawnting this Article. , shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Ef-I am the person responsible for the construction activities of this project, for satisfying the requirements of this'
permit, and tar any civil or criminal penalties incurred due to violations of this permit.
Ef1*-T}tie information submitted in this NOI is, to Ow hest of my knowledge and belief, true, accurate. and complete
based on my inquiry of the person or persons who manage the system, or otiose persons directly responsible for
gathering the infrxmation.
Ef I will abide by all conditions of the NCGO10000 General Permit and the approved Erasion and Sediment Control
Plan,
lar"�If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (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.
ER""I'hefeby request coverage under the NCG010000 General Pc it 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.
Prajert Name (mejsd mulch AIa): WY-
Specific Lot Numbers (must match Alb): rV _
Pefmittee Irnust match 61): '.n_,LA.rr
Legally Responsible Person (must match 92 & 83):(]
nI��
Title of legally Responsible Person (mast match fi3h): i`}t.i.�]+c
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Pelson -
Phone Nurnbef: ,� _ � - WV 55
ture Al-egalfy Responsible Person or Authorized Individual
dv •J •�.
Date
IMPORTANT NM: this form must be sgrred by a responsible corporate officer that owns or operates the construction activity,
wde us a prriidrnr, sweet ury, t rra%urrr, ry vire prr %kk—nr, ear a manugrr that i% authrrrirrrl in arr rudvncr with Piper IV, Section F,
Inter [Gl of thr W601 MW permit,