NCC222772_NOI Signed Certification_20220803

NCGO1 Notice of Intent (N01) Cert'lof*lcat
Directions:
For
Print this form, complete, scan and upload to the electronic N
Then, mail the original form to the NC DEMLR Stormwater Program (with 5100 check ilpaying by check) J
Division of Energv, 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 YO
THE FORM YOU MAIL MUST BE COMPLETED WITH
Per Alr General Statute 14-3-21-5 6R 1i)-
certlfication in any application, record, report, plan, or other document filed or required to be maintained under th
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine no
exceed ten thousand dollars ($1 0jf 000).
UR APPLICATION H
N ORIGINAL SIGNA
S BEEN
CCEPTED
PLETE.
TUBE (NOT DIGITAL) [40 CFR 12212
Under penalty of laws I certify that
any person who knowingly makes anyfalse statement, representation, or
check all boxes to indicate your agreement):
L,o,j. I am the person responsible for the constructi
permit, and for any civil or criminal penalties i
on activities of this project, for satisfying
ncurred due to violations of this permit.
the requirements of this
U The intormation submitted in this N01 is, to the best ot my knowledge and belieT, true,, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible fo
gathering the information.
41
I will abide by all conditions of the NCG010000 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.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): (344L 8)c-(V� Oe
Specific Lot Numbers (must match Alb):
Permittee (must match Bl): Br -Vora kq 6o r r1
Legally Responsible Person (must match 82 & B3):
Title of Legally Responsible Person (must match B3b): L eA C2 I& n� L 0. 0�, :�- 1`Gr
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number. DOLI 4SIr I r?4r.1
Signature of Legally Responsible Person or Authorized Individual
Date,
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