NCC231095_NOI Signed Certification_20230419

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check /fpcJy/.ng by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITll AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation, or
certificat.Ion in any appl.Ication, record, report, plan, or other document filed or required to be mainta.Ined under this
Article or a rule implementing this Article . . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law,I certify that (check all boxes to indicate your agreement):
E I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
E The information submitted in this Nol 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
gathering the information.
E I will abide by aH conditions of the NCG010000 General Permit`and the approved Erosion and Sediment Control
Plan.
E lf the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010cOO General Permit,I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
E1herebyrequestcoverageundertheNCG010000GeneralPermitandunderstandt;atcoverageunderthis
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must mcrtch Af cr):C&D Land fill, lnc. Phase 3
Specific Lot Numbers (mList mcrrch Af b): n/a
Permittee (mustmorch 8|): C&D Land fill, lnc.
Legally Responsible Person (must match 82 & 83):April Whitehurst Haltigan
Title of Legally Responsible Person (must motch 83b):President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:n/a
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activ.Ity,
such as a president, secretary, treasurer, or v-Ice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCGO10000 permit.