NCC232350_NOI Signed Certification_20230804

NCG01 Notice of Intent (1401) Certification Form
Directions:
Print this form, complete,scan and upload io the electronic NO I.
Then, mail the original form to the NC DEMLR Stormwater Program (with 5100 check if paying by check)at
Division of Energy, Mineral& Land Resourres 5to►mwater Program
512 N. Salisbury Street.69-Floor(Office 640K)
1612 Mall 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 ORIGINALSIGNATURE(NOT DIGITAL) 140 CF8 122.221
Per NC 6eneral5totute 143-215.68(i). any person who knowingly rrankes any false statement, representation, or
certification rn any application, record, report plan, or other document fired or required to be maintained under this
Article or❑rule implementing this Article.. .shall be guilty of o Crass 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that (check all bakes 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.
The information submitted in this NOI is, to the best of my knowledge and belief, trua, 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,
I will abide by all r-anditions of the N CIS 010000 Gene raI Permit and the approved Erosion and Sediment Control
Plan.
If the approves!Erosion and Sediment Control Plan is not compliant with Part II(5tormwater Pollution
Prevention Plan) of the NCGQ1Q000 General Perini[ I will nonetheless erasure that all conditions of Part II of the
permit are met on the protect at all times
® I hereby request Coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements Tar the discharge(sj and is enforceable In the same manner as an
individual permit
Project Name (must match Ala):
Specific Lot Numbers (must match AIb): }�
Perm ittee(must match B11: A
Legally Responsible Person (must match 82& 83)
Title of Legally Responsible Person (masr match B3b): FYI PrtvA't],�\-
Print Name&Tftle of Signed If Authorized
Individual DifferS from Legally Re5ponsible Person:
Phone Number: CTIIIOlt
Signature of L Ily Responsible Person orluthurized Individual Date
• IMPORTANT NDrE: Phis farm must be signed by o responsible corporate officer that owns or operates the construction activity,
such as a presidenr,secretary, treasurer, or vice president, or a manager that is authorized in accordance with Parr IV, Section 8,
Item WSJ of the NCG01Qi7Wperrrut.