NCC232272_NOI Signed Certification_20230804

NCG01 Notice of intent (N01) Certification Form
Directions:
Print this Form, complete,scan and upload to the electronic NO].
Then, mail they original form to the NC DEMLR Stormwater Program (with$100 check if paying by check)at:
Division of Fnergy, Mineral& Land Resourres Stormwater Program
S12 N. Salisbury Street,6" Floor(Difke 640K)
1612 Mail Service Center
Raleigh, NC 2769%1612
DO NOT MAILTHIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)140 CFR 1I2.221
Per NC General Statute 143-I15.6B(i), any person who knowingly makes ony false statement,representation, or
certification in any application,record, report plan, or other document filed or required to be maintained under this
Article or a rule implementtng this Artirk- , shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed tpn thousand dollars ($10,000).
Linder alty of law, I certity that(Check all boxes to indicate your agreement):1 am the person responsible far the construction activities of this project, for satisfying in the requirements of t is
q
ZThe
rnit.and for any civil or criminal penalties incurred due to violations of this permit.
infofrndtion submitted in this NOi is, to the best of my knowledge and belief,true, accurate,d n d comp le tr
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
7ering the information
wi11 abide by all conditions of the Y&(,jo],oC1Clf3 Gengrai Permit and the approved Fras"son and Sediment Contml
P
It the approved Lrosion and Sediment Control Plan is not compliant with Psrt 11 (Stormwater Pollution
Prevention Plan)of the (w' rai Permit. I will nonetheless ensure that all renditions of Part 11 of the
mit are met on the project at all times,
f hereby reclttest coverage undr.r the NCG010000 C.ient•ral Permit and understated that coverage tinder this
permit will constitute the permit requirements for the discharge(s)dnd is enforceable in ihP same mariner as fan
individual permit.
Project Name (must match Ala):
Specific Lot Numbers(must match A1b): ,— f a -7
Permittee{must match Bl): j�,r i Cat• ��/0 , y
Legally Responsible Person(must match BJ& 6.3)� !'��I�.f-IJo46 L
Trtle of Legally Responsible Person(must match 63b):
Print Name&Title of Signed it Authorized
Individual Differs from Legally Responsible Person:
Phone Number: f - [.
Y C� 2,V?,3
Signature of Legally Responsible Person or Authorized Individual Date
' IMPORTANT NOTE: This form must bar signed by o responsible corporate officer that awns or operates the construction activity,
such asa president srcrctory,treasurer,or voce president,or a manager that is authhorirrd in accordance with Parr IV, Section 8
Item(6)of the NC6010000 pefml-