NCC231106_NOI Signed Certification_20230425

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NCGO1 Notice of Intent (NOI) Certification Form
tab
Directions
te,scan and upload to the electron" NO1 m by check)at
Print this form,complete,Stormwater ram(with 5100 check i/poY 9
n i form of Etnergy,
gN DMMKal&Land Resources Stormwater Program
cps fur D Then,marl the ung (Office r3a0lf)
Division of E 2 N.
Street,6^Floor
512 N.Salisbury
1612 Mail Service Center
Raleigh,NC 27699•1612
shiftCOMPLETE
t COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)(40 CFR 122.221
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED
THE FORM YOU MAIL MUST representation, a
curlperson who knowingly makes any false statement, repr r this
n,or other document filed or required to be maintained aide
Per NC Generalinan application,record,,any Pt include t fine not to
certification any leetgtireport,Pb guilty ofo Closs 2 misdemeanor which may
Art"lt or o rule implementing this Article. shall be g Y
er., exceed ten thousand dollars(S10,000)
i.
All I11 Under penalty of law,I certify that(check all boxes to indicate your agreement) t he requirements of this
'jfor satisfying s $ � I am the person responsible for the construction activities of this protect,
permit,and for any civil or criminal penalties incurred due to violations of this permit
and belief,true, and
jEi
The information submitted m this NOI is,to the best of my knowledgee,accurate,directly responsible o completeple for
based on my inquiry of the person or persons who manage the system,or those persons
gathering the information.
0 I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit,I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0 I hereby request coverage under the N00010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Protect Name(must match Alo): Mirtek Properties
Specific Lot Numbers(must match Alb): f�
Permittee(must match 81): S `L14,4:A.A \ISA \ems\",sue)
Legally Responsible Person(must match 82&83): Gtvq,v I Cyr IM A‘ovir(
Title of Legally Responsible Person(must notch 83b).• i:h,3l. Q, J f , Mtr�L( i„
Name&Title of Signed if Authorized Individual I -
Differs from Legally Responsible Person:
Phone Num r: `111- 30 i Ne)►i9
-l4,01,14,4Sig re of Le II sibie Person or Authorized Indvidual
• IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction act►vlty,
such as a president,secretory, treasurer,or vice president,or a mo'ioger that is authorized in accordance with Port IV,Section 8.
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