NCC233366_NOI Signed Certification_20231113

NCGO1 Notice of Intent (NOI) Certification Form
Direct n;,..
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,6*Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DC NOT MAILTHIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS SEEN ACCEPTED AS COMPLETE.
TH)<FORM YOU MAIL MUST DE COMPLETED WITH AN OftIGINAL SAGtdATUlti (NOT DIGTTAI.) [40 CFR 122.-221
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 Artide. ..shall be guilty of a doss 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under natty of law, I certify that(check all boxes to indicate your agreement):
ICl I am the person responsible for the construction activities of this project,for satisfying the requirements of this
mit.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,true, accurate,and complete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
hiring the information.
i will abide by all conditions of the ty,CGO!g4lp9 Generalygrmrut and the approved Erosion and Sediment Control
Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCGOI tk1 Gareral Pep , I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
i hereby request coverage under the ':CGOIOJ,OO!Grrrra' P r•rii'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.
Name of Project(must match Ala): i11--t; lit/ e 1?e i ,'d c . €
Specific Lot Numbers(must match Alb):
Legally Responsible Organizational Entity(must match 81): ,14.ei,e i Si0 vrt
Legally Responsible Person(must match 82&83): Ac VeJ1 .4-1)1,f,„r
Title of Legally Responsible Person(must match 83b): QW/f e,
Name&Title of Signed If Authorized Individual
Differs from Legally Responsible Person! _
Phone Number: 0 y— 7/) - !rail
c -.<17f2./A-si: -ji,‘-, ithozi < A 0 01.2
Signature of Legal Responsible Person or Authorized Individual Date
` IMPORTANT NOTE: This form 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 8,
rtem 16)of the NCG0i0000 permit.