NCC230538_NOI Signed Certification_20230302

NCGO1 Notice of latent (NOI) Certification Form
Print this form, complete, scanandupload to the electronic NOL
Then, mail the original farm to the NC DEP,4LR 5torrnwater program (with $100 check ifpaying b chec
Division Of Energy, Mineral & Land Resources 5tormwater Program Y k) at:
512 N, Salisbury Street, fi� Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO
THE FORM YOU MAS' ,`��a1��' i E iW�3 P€ � i �s, , , o 0 �. �!€:A19 �N iiiAS EE C'- TED A5 rj %4PL y �.
y A ORIGINAL SIGNATURE (NOT t3$GiT:kL) !40 CEP :f 3„21y;
Per NC General Statute 143-215. 613 i , an
certification in any application, record, report, rplanohedo son who knowingly
cant fifed or re
kes y false statetrtent, representation, or
Article be
or a rule irriplernenting this Article _ .. shoJJ be guilty of a Class 2 misdemeanor whiquired ch may include aundeer this
exceed ten thousand dollars ($10 t�QQj,
f not to
Un�71
aity of law, I certify that (check all boxes to indicate your agreement).
m the person responsible for the construction activities of this project, for satisfying the requirements of this
p rrnit, and for any civil or criminal penalties incurred due to violations of this permit.
The information submitted in this N©I is, to the hest of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system
tiering the information. , or these persons directly responsible for
ill abide by all conditions of the NCG{}ltlaf}p General
Pi 'n. Permit and the approved Erasion and Sediment Control
If the approved Erosion and Sediment ment Control Plan is not compliant with part It (Stormwater Pollution
Prev ration plank of the tiCG01D00p General Permit
t are met on the project at all times. f will nonetheless ensure that all conditions of Part 11 of the
mi
I hereby request coverage under the ; CG01- -- �Seneral Permit and understand that coverage under this
permit will constitute the permit requirernents for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must mptchAla):
Specific Lot Numbers (must match Alb):
Permittee (must match BZ):
Person (must match B2 & B3
Title of Legally Responsible Person (must match
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number:
4"- 7
Signature & Le'gally Responsible Person or Authorized individual
Dant
IMPORTANT NOTE. This jorm must be signed by a responsible corporate officer that owns or operates the c
such (6 a president secretary, treasurer, or rice president, or a Manager that is authorized in accorclance with part ►V Section B
Destruction activity,
Item (�) of the iVC6ti20000 perrrtit_