NCC224082_NOI Signed Certification_20221212

NCGO1 Notice of Intent (N01) Certification Form
Directions11
Print this form, cornpletep scan and upload to the electronic N1.
Then rail - FR Stormwater Program(with 100 check if pays � b h� � at:t�� o���r�a1 �orr� t� the ��
Division of Energy, Mineral & Laird Resources Stormwater Program
512 N, saksbury Street, ", Floor (Office 40 )
1612 Mail Service Center
Raleigh, NC 27699-2612
OQ NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCENTED AS COMPLETE.
THE FORM YOU MAIL. MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122,22)
Per NC Gen eral S to Lute 14 3 -2 1 t an y p erson who kn o wingl i2k es any false sto to me rn t, repres en to tion, or
c rti r cation n any applica tf on, record, r ep ort, plan, Ior other doc urnent filed or required to b e maintained under this
Article or a rule *m l e tiro this Article t . * c1l be it o a `IOS m emeanor v is may include a fine no t t
exceed tern tho usand dollars ($10, 000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
zoo�l am the p arson rep P rio sible for the construction activities of this project, for satisf i ng the r q uire m eats of this
permit, and f or airy civi I or criminal pena Ities i n u rr d du a to violations of this perm it.
The information submitted in this I is, to the best of m Ikno led and belief, true accurate, and opl t
based on 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 NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with part it (Stormwater pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of Part ll of the
ZIrmit are met ors the project at all times.
herebyrequest coverage under the NCGO10000 General Permit and understand that coverage urnder this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the wine manner as an
individual permit.
Project Name (must motchAlo): Wo
Specific Lot Numb rs (must match A1b)+
Permittee (must match BI ): La,� b u,•
v icw fad- 3_ _aJ, �,
Legally Responsible Person must match $2 & B3}:
Title of legally Responsible Person•(must mach 836):
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phase Number: ? yg - 3 9
- y Z
L LC.
� z z
Sign at rp Legally Resp n 'Dfe ersan or Authorized individual Date
` fMPORTANT JVUTEE This form must be signed by a respansihle corporate officer that o►vns or opera tes fhe con rtrud+on ac[ivrty,
such as o president, secrr[ory, rreosurer, or vice preside rr[, or a manQgcr [har is auchvriied in accordance with Part I11, Section B,
item (6) of the IVCG010000 permit,