NCC232827_NOI Signed Certification_20230920

NCG01 Notice of Intent (NOI) Certification Form
C8*stinny;
Print this form, complete,scan and upload to the electronic N0.
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 StunnvxaterPrugmm
512 N. Salisbury Street,6'" Floor(Office 540K)
1612 Mail Service Center
Raleigh, NC27699'l6l2
DO NOT MAIL THIS FQK.1OR PAYMENT UNT/LYOUR APPLICATION HAS BEEN ACCEPTED ASCOMPLETE,
THE FORM YOU MAIL MUST BECONIpLETE0 WITH AN ORIGINAL SIGNATURE(NOT Q|G|r^L) [4O{FR12Z.22]
Per N[General Statute 143-215.5B(i), any person who knowingly makes anyfolse statement, representation, or
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this
Article oro rule implementing this Article. . .shall 6e guilty nfo Class 2 misdemeanor which may include o fine not to
exceed ten thousand dollars/$2400CV.
Under penalty of law, | certify that (check all boxes to indicate your agreement):
[71 |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.
F7 I The information submitted in this NO] is,tothe best ofmy knowledge and belief,true, accurate, and complete
based on my inquiry ofthe person o/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,
�1 If the approved Erosion and Sediment Control Plan is not compliant with Part || (Stomow/ater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met an the project at all times.
[� 1 hereby request coverage under the NICG010000 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(nnustmotchA2o): EU[D|iD8
Specific Lot Numbers (must match A2b):
Permittee(must match 02): 4M Enterprises
Legally Responsible Person (muotmotch8J& 83): Serge R0zu[n
Title of Legally Responsible Person (must match 83b): Owner
Print Name&Title uf Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 888969691 11-7
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80nat of BaDV Responsible Person or Authorized Individual Date
* 0NPOnT4wrNOnE, Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such 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 N[G0z0n00permit.