NCC230217_NOI Signed Certification_20230125

wig ons:
Printth`sibnm6 complete, scan and upload to the electronic NOL
Then, avail the Boron to the NC DEMLR Stormwater Program (WM $100 deck if p*W by dwdc) at
Division of Eat, Wwrai & carve}.Resources 5tormwaterProgram
512 M. Spry &k Flour (Olhoe 6
1612 Mad Sertnte Center
Rak*p% 2 16i2
DO NOT MAIL THIS FORM OR PAYMerin` UIIQ�L YOUR r 2PUCAMON HAS BEEN ACCERED AS COMPLETE.
rdE FORM TO€3 MAIL MUST RE COMPLETED WITH AN ORIIGIWAL SIGNATURE MOT DIGITAL)140 CFR 122.22j
PerAIC GenernISUdate143-2_15AS ft , anypersors lc iyma#6esuayfidsesep or
nerbf=dwn in emy*gw&nbw , rec ont report p#ua; aretherdocunwat led orn*dneal to he mmWevied under this
Artidearande` thisArfide_-_sbWV6e9uWy fa Ckw2mkdemrmwwhkfinvaye afiwnoito
exceed We dwuwWd *ms ($:dtJ:� )
Under penalty of law. ! cen* that (dw& all borers to lirmlicate vow agent):
T/ i am the person responsible for the construction activities of this project, forte the requirements of this
permit, and for any citric or criminal penalties incurred due to vans of thispermit.
i3'^ the information submitted in this Hot is, to the best of my knowledge and beW,17ue, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
/ gatheringthe inforrraation•
C9' t uAll abide by all conditions of the MCGO10036 General Perm a and the approved Erosion and Sediment Control
Flan.
12"j if the approved fusion and Sediment Cormxg Plan is not compliant %with Part li (Storrtrwater Pollution
Prevention Plan) of the P,11, rCGO'1000 01 GerzeraI Per _it. l will nonetheless ensure thatall conditionsofPad H of the
emit are met on the project at all times-
t ri II hereby request coverage underthe f CG !QCOO General Re- alit and understand that coverage under this
permit will consfitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
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Specific tot lWsr s(anotnia"AM):
Legally Ftespons2de Oqpnzamnal EMW (Mist Ma" W): ,-e�
Legally Responsible Pin Omist makh 82 & $3) l I mo, 1 i
True of LegWly Responsible Person (mast match 83bk f a S �Or —
hLWne &Tale of SWied If Mdwrbed kaWidual
Phone Number_
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Signature of legaft Responsible Pers6n cw Wuftwihed trrriiOdual Date _
ThisfimmmusthesOmdbyanqwnsftewrponzteqgkm OWusara doe CONS&UCOMa r.
srrchasafwesideKspry,treasraer,orrioepoeWntera manmjertiwtisovfioimdr,ac xaevMhPwriV,5eeftn8,
Item (6)ofthe AMMOD fiownit.