NCC223586_NOI Signed Certification_20221019

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at.
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO N07 MAiL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General tatute 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certification in ny application, record, report plan, or other document filed or required to be maintained under this
Article or a rule Ijmplementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thou and dollars ($10,000).
Under p alty law, I certify that (check all boxes to indicate your agreement):
I m theperson responsible for the construction activities of this project, for satisfying the requirements of this
rmit, and for any civil or criminal penalties incurred due to violations of this permit.
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
t
1hering the information.
Xn,Iftheap
bi e by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
roved Erosion and Sediment Control Plan is not compliant with Part If (Stormwater Pollution
Preventi Dn Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of Part II of the
rmit are met on the project at all times.
! hereby request coverage under the NCG010 000 General Permit and understand that coverage under this
permit 411 constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
indiVdu I
I permit.
Project Name (must match Ala): 1 Z�
Specific Lot Numbers (must match Alb): k -37,-
Permittee (must match Bl ):
Legally Responsible Person (must match B2 & B3):
Title of Legally Responsible Person (must match B3b):
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: (,
Signature ¢f
onsible Person or Authorized Individual
�2;��/Z� 2
Date
IMPORTANT NOTE: This form 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 authorized in accordance with Part iV, section B,
Item (6) of the NCG010000 permit.