NCC230353_NOI Signed Certification_20230208

NCG01 NoUce of Ment (NOI) Certif caUcn Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying, ly 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 NOT MAjL TMS FORM OR PAYMENT UNTVL YOUR APPUCAT1oN HAS BEEN ACCEPTED AS :O�li PLETE.
THE O PLTLI VOU hAl A j L MUM U BE COMPLET D VV9 o V: =aN 0, P�jC- id�AL S�O6c�, T U R E �N,3 a U i G 0 u:-"�L� I41 1 C F R 122.22]
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, represel tation, or
certification in any application, record, report, plan, or other document filed or required to be mointair ed under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may incluc e a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Q✓ I am the person responsible for the construction activities of this project, for satisfying the req jirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Q✓ The information submitted in this NOI is, to the best of my knowledge and belief, true, accurai e, and complete
based on my inquiry of the person or persons who manage the system, or those persons direc ly responsible for
gathering the information.
0✓ 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and ' ediment Control
Plan.
0✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater P )Ilution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditioi s of Part II of the
permit are met on the project at all times.
Q✓ I hereby request coverage under the NCGO10000 General Permit and understand that coverag � under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the si me manner as an
individual permit.
Project Name (must match Ala): Williams Grove- Phase 4
Specific Lot Numbers (must match Alb):
Permittee (must match BV: C.T. Williams Corporation
Legally Responsible Person (must match B2 & B3): Cecil Williams
Title of Legally Responsible Person (must match B3b): PRESIDENT
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 252-205-1151
Signature of Legally Responsible Person
Individual
Da e
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the con: rruction activity,
such as a president, secretary, treasurer, or vice president or a manager that is authorized in accordance with I art IV, Section B,
Item (6) of the NCGO10000 permit.