NCC232755_NOI Signed Certification_20230913

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 N[DEMLR 6tnmovvaterPno8ram (with$100 check if paying bycheck) at:
Division of Energy, Mineral & Land Resources SturmvvaterProgram
SlZN.Salisbury Street,6^ Floor(Office 640K)
161Z Mail Service Center
Raleigh, NC27699'l6l2
DO NOT MAIL THIS FORM QR PAYMENT UNTIL YO0�APPL|�A�|K�NHASBEENACCEPTEDASC{}N1PLETE
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE~~ (NOT m8�
.,^ ,2_^
Per N[General Statute 243-2DI68(i), any person who knowingly makes onyƒobe statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required tobe/no/nto/nedunoerthis
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 ($24000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
A 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.
IX The information submitted in this NO| is,to the best ofmy 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
gathering the information.
�
=, I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
[X If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGD1OOUD General Permit, |wiU nonetheless ensure that all conditions of Part || of the
permit are met on the project at all times.
EX I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharQe(s) and is enforceable in the same manner as an
individual permit.
Name of Project(must match A2o): Neuse Colony VV\&TpExpansion
Specific Lot Numbers(must match A2b): N/A
Legally Responsible Organizational Entity(must match 82): Aqua North C3[O|iO8' Inc.
Legally Responsible Person(must match 8J& B3): Lauren Raup-P|UrDrDe[' F^.E.
Title uf Legally Responsible Person (must match 83b): Engineering Manager
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 9196536875
/l� / � /� 0 -�+�( // ' ~-/ r,~~.,
Signature ofLega||y Rpl�onu�J� Peoon orAuthorized |ndividua| Date
* mxpOmn*mTNOTE. This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as opresident,seoruzqK treasurer, or vice president, or manager that is authorized in oonu/oxco with Part/K Section B,
Item(6)of the N[G02D0O0permit.