NCC223227_NOI Signed Certification_20220921

Directions:
Print this form, complete, scan and upload to the electronic N0L
Then, mail the original fonntotheNCDE&4LR6torrnvVaterProgrann(vvhh$1DDcheckifpoyingbycheck)at:
Division cfEnergy, Mineral & Land Resources StormvvaterProgram
512N.Salisbury Street, 6mFloor (Office 64OK)
1613Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM ORPAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122,221
Per NC General Statute 143-215.6B (i)cny person who knowingly makes cnyfalsestatement, representation, or
certification in any application, record, report, plan, orother document filed orrequired tobemaintained under this
Article mrorule implementing this Article ... shall beguilty qfuClass Jmisdemeanor which may include ofine not tn
exceed ten thousand dollars, (�14000).
Under penalty oflaw, | certify that (check all boxes tmIndicate your agreement):
rA
JJJ I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
h�| The information submitted in this NO[ is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information,
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| will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart Uufthe
permit are met on the project atall times.
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| 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): Lo� /ZS L:n*r-N - ?3z3 4tAe!y,*-n kes"
c Lot Numbers (must match Alb): — o
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Legally Responsible Person (must match B2 & B3): A/RA FAe 4Ae.- . ..... .
Title of Legally Responsible Person (must match B3b): ojup%tr
Name @kTitle ofSigned ifAuthorized Individual
LegallyDiffers from b| -
t" � ', gall. ~
signature
ponsible Person or Authorized Individual
~ IMPORT4wTNO7E/ This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such uoopresident, secretary, treasurer, nrvice president, nromanager that isauthorized /naccordance with Part IV, Section f,