NCC233645_NOI Signed Certification_20231211

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,com Bete, scan and upload to the electronic NOI.
Then, m al the original form to the NC DEM LR Storm water Program (with $120 check if paying by check)
at:
Division of Energy, M neral & Land Resources Storm voter Program
512 N. Salisbury Street, 6th Floor(Office 640K)
1612 M al Service Center
Raleigh, NC 27699-1612
THE FORM YOU M AIL M UST BE COM PLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.68(i), any person who knowingly m ckes any false statem eit, representation, or
certification in any application, record, report, plan, or other docum eit filed or required to be m dntained under this
Article or a rule im Clem eiting this Article. . . shall be guilty of a Class 2 m sdem(prior which m cy include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreem eit):
✓❑ am the person responsible for the construction activities of this project,for satisfying the requirem sits of this
perm t, and for any civil or crim hal penalties incurred due to violations of this perm t.
ET he inform a:ion subm tted in this NOI is,to the best of m yknowledge and belief,true, accurate, and corn riete
based on m yinquiry of the person or persons who m aiage the system,or those persons directly responsible for
gathering the inform a:ion.
0l will abide by all conditions of the NCG010000 General Perm t and the approved Erosion and Sedim sit Control
Plan.
El f the approved Erosion and Sedim Ent Control Plan is not corn iliant with Part II (Storm water Pollution
Prevention Plan) of the NCG010000 General Perm t, I will nonetheless ensure that all conditions of Part II of the
perm t are met on the project at all tim a.
0l hereby request coverage under the NCG010000 General Perm I and understand that coverage under this
perm I will constitute the perm I requirem efts for the discharge(s) and is enforceable in the sam em airier as an
individual perm I.
Project Nam e(m tst m ctch Ala): Sterigenics - Water Line Extension
Specific Lot Num hers (mist m ctch Alb):
Perm ttee (m wt m ctch 81): Sterigenics Radiation Technologies, LLC
Legally Responsible Person (m Est m ctch 82& 83): M chael P. Rutz
Title of Legally Responsible Person (m cst m ctch 83b): President, Sterigenics Radiation Technologies, LLC
Print Nam e&Title of Signed if Authorized
Individual Differs from Legally Responsible Person: M a-k Sim pson, Director
Phone Num ter: 440-262-1410
Date a,12aso 4110=00 12/5/23
Signature of Legally Responsible Person or Authorized Individual Date
* 1M PORTANT NOTE: This form m u;t 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 m wager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 perm t.