NCC232672_NOI Signed Certification_20230907

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NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this 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:
Division 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 143-215.68(i), any person who knowingly makes any 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 implementing this Article... . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
n 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.
Q The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, and complete
. based on my inquiry of the'person or persons who manage the system, or those persons directly responsible for
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gathering the information.
El I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
', Plan.
Q 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.
• Q 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 Ala): Hood Swamp Site
Specific Lot Numbers(must match Alb): •
Permittee (must match 81): Restoration Systems, LLC
Legally Responsible Person (must match 82& 83): John Preyer
Title of Legally Responsible Person (must match 83b): Director of Operations
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 919-27 419
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gnature o 'e ally Res risible Person or Authorized Individual ( Date
* I 0 ANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
3such as a president,secretary, treasurer,or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.