NCC231520_NOI Signed Certification_20230518

NC 01 Notice of Intent (NCII) Certification Form
Directions:
Prin1<this form,complete,scan and upload to the electronic NOI.
Then, mail the original foJ(.m to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Divis on of Energy,Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,6tn Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FOR OR PAYMENT UNTIL YOUR APPLICATION HA5 BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MU T BE COMPLETED:WITH AN ORIGINAL,SIGNATURE NOT DIGITAL1 Flo CIF R 122:22]
Per NC General Statute 143-215 68(1), any person who knowingly makes any false statement,representation,or
certification in any application,¶�jjecord, report,plan, or other document filed or required to be maintained under this
Article or a rule implementing t!is Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($1i/000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
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.
Er The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate,and complete
based on my inquiry of:he person or persons who manage the system, or those persons directly responsible for
gathering the informati•n.
a I will abide by all Condit ons of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the CG010000 General Permit I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the •roject at all times.
121/I hereby request coverage under the NCG010000 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.
Project Name(must match,41a): 39 L-1 0 SQ c as C-A
Specific Lot Numbers(must atch A1b): SS
Permittee(must match B1): `phi .y1,„, 1 1 QQ(Yv2�s3
Legally Responsible Person ( nust match B2& B3): 3 hQn xbr 1 14051 y1O,3
Title of Legally Responsible Person (must match B3b): ,Sf 1aYvy1oY` T pth
Name&Title of Signed if Authorized Individual J
Differs from Legally Responsible Person:
Phone Number: �.�1Q(i �D o��`�9
5776.
Legally Respo .ble Person or Authorized Individual Date
* IMPO• •air
'OTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretary, trasurer,or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.