NCC222797_NOI Signed Certification_20220805

NCG01 Notice of Intent (NOI) reification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form tc the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division o-: Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
❑O NOT MAIL THIS FORM OP PAYMENT UNTIL YOUR APPLI TIONI HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGIN4 SIGNATURE (NOT DIGITAL) [40 CFR 122,221
Per NC General Statute 143-215.6E (i), any person who knowingly makes an� false 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 Ar'icle ... 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 (c-ieck all boxes to indicate your agree ent):
C' 1 am the person responsible for the construction activities of this prrdject, for satisfying the requirements of tlris
permit, and for any civil or criminal penalties incurred due to + iolatibns of this permit.
R. "' The information submitted it this N01 is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the p ?rson or persons who manage th system, or those persons directly responsible for
gathering the information.
I will abide by all conditions of the NCG010000 General Permi and �he approved Erosion and Sediment Control
Plan.
If the approved Erosion and :pediment Control Plan is not combliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGC 10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
CV"' I hereby request coverage urder the NCGUlUODU General Pen it an understand that coverage under this
permit will constitute the per mit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit. i
Name of Project (must match AlG): �,e�4
W. tiv it,
Specific Lot Numbers (must match Alb): t7Q(p � 2
Legally Responsible OrganizationzI Entity (must match B1): es-("
Legally Responsible Person (must match B2 & B3): $6ow Fd&Ac 4
Title of Legally Responsible Person (must match B3b):
Name & Title of Signed if Authorized Individual
Differs frum Legally ReSponSible Person:
Phone Number. (113) 0).7 J ID7jDa
Ily Responsible Person or Authorized Individual
2Z_
ate
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasura:-r, or vice president, or a manager that is authorized in accordance with Part rv; Section 8,
Item (6) of the NCG010000 permit.