NCC231515_NOI Signed Certification_20230518

NCG 1 Notice of Intent (NOI) Certification Form
Directions:
Print his 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 by check)at:
Divisidn 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 WITH AN.ORIGINAL'SIGNATURE NOT DIGITAL][40 CFR 122.22]
Per NC General Statute 143-215. B(i), any person who knowingly makes any false statement, representation, or
certification in any application, rIl cord, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing th s Article. . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($1 ,000).
Under penalty of law,I certify thrt (check all boxes to indicate your agreement):
13/ I am the person responsible for the construction activities of this project,for satisfying the requirements of this
permit, and for any civil r criminal penalties incurred due to violations of this permit.
[ "The information submit ed in this NOI is,to the best of my knowledge and belief,true, accurate, and complete
based on my inquiry of t a person or persons who manage the system,or those persons directly responsible for
gathering the informatioln.
dI will abide by all conditions of the N00010000 General Permit and the approved Erosion and Sediment Control
Plan.
Er 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 11 of the
permit are met on the project at all times.
[l I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute t e permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name(must match la): 39 5a 3Qd( J , C*
Specific Lot Numbers(must tin atchAlb): gb
Permittee(must match B1): Si' Myth ) .6flitrliln
Legally Responsible Person(jnust match B2& B3): �h( An.,l`j]/\ IQ.i_o_an
Title of Legally Responsible Person (must match B3b): Shay _DIA__ 1„QS
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: ca . 61\ (•Q - &'59
40
- . e•- -- ••nsi. e 'erson or Authorized Individual Date
* IMPOR , ,OTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretary,taFeasurer, or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.