NCC222195_NOI Signed Certification_20220615

NCG01 Notice of Intent (1401) rertV.e�aii�+±� Form.
Directions.
Print this foam, complete, scan and upload to the electronic NOL
Then, mail the original forrn to the NC DEM LR Sto rmwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral 8c 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.
_HE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse 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 ... sha!l be guilty of a Class 2 misdemeanor which may include ❑dine not to
exceed ten thousand dollars ($10,000).
Under penalty of haw, l certify that (check all boxes to indicate your agreement}:
Q I am the person respvnsilble for the construction activities of this project, for satisfying the requirements of this
permit, and for any divil or criminal penalties incurred due to violations of this permit.
�✓ The information submitted in this NO] is, to the best of my knowledgeand belief, true, accurate, and complete
based an my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
i will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Phan.
Q If the approved Erasion and Sediment Control Phan is not compliant v+riih Part If (Stormwater- Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Fart 11 of the
permit are met on the project at all times.
✓[] I hereby request coverage under the NCG030000 General Permit and understand that coverage under this
permit wil[ canstitute the permit requirements for the d i-scha rge(s) a nd is enforceable i n the same manner as an
individual permit.
Project Name (must match Ala); Roxboro Borrow Area 2 Excavation Plan
Specific Lot Numbers {must match A3b�:
Permittee (must match BTU: duke Energy Progress LLC
legally Responsible Person (must match B2 & B3): Duncan Brewer
Tile of Legally Responsible Person (must mach B.3b). Project Director
EVMV-00*�
Name & Tine of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 336-330-2058
Signatur of Legally Responsible Berson or Authorized Individual
Date
IMP T 1 TE: Thl*sform 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 authorizedin accordance with Part IV, Section
Item of the NCGO10000 permit.