NCC240506_NOI Signed Certification_20240222

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 $120 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
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):
❑✓ 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.
E✓ 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
gathering the information.
❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
E 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.
El 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): Neville Street Drainage Improvements
Specific Lot Numbers(must match A1b):
Permittee (must match 81): City of Fayetteville
Legally Responsible Person (must match 82& 83): Byron Reeves
Title of Legally Responsible Person (must match B3b): Assistant Public Services Director - Engineering
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 910-433-1301
2/21/24
natur of Legall esponsible 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 B,
Item(6)of the NCG010000 permit.

Byron Reeves
From: Tom Murray <[e-mail]>
Sent: Tuesday, February 20, 2024 9:35 AM
To: Byron Reeves
Cc: Jason Sesler
Subject: [EXTERNAL]FW: Neville Street- e-NOI (NCG01) Form for Submittal
Attachments: Item#9 NCG01-eNOl-Certification-Form-20231013-DEMLR-SW.pdf; Item #5 Approved
Permit cumbe-2022-074.pdf; Item #6 Neville Financial Responsibility Form Nov2021
Fillable-Signed.pdf; Item#7 Neville Street Location Map.pdf
Follow Up Flag: Follow up
Flag Status: Flagged
Byron
See Jason's instructions below for completion of the Neville NCG01. You will need to finalize the submittal as it needs
original signatures. If you have any questions or require any additional information, please let us know. Thanks!
Tom Murray, PE
Raleigh Stormwater Program Manager
WK Dickson & Co.,Inc.
720 Corporate Center Drive
Raleigh, NC 27607
Office: 919-782-0495
Mobile: [phone]
Email: [e-mail]
www.wkdickson.com
Connect with us:Facebook I Twitter I Linkedln
From:Jason Sesler<[e-mail]>
Sent:Tuesday, February 20, 2024 9:17 AM
To:Tom Murray<[e-mail]>
Subject: Neville Street-e-NOI (NCG01) Form for Submittal
Tom,
Byron will need to log on to the Website to complete the form using the below user name and password. Link for e-NOI
(NCG01)form:
Click here to complete your form
User Name: [e-mail]
Password: Neville Street Drainage
Bryon will need to complete Section D & E. Sections A-C are complete; however, Byron should review Section C Billing
Information Item#11 &#12 and determine if he wants to change.
Section D:
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Please upload Item#5, #6, #7, &#9. Item #5-#7, #9 are attached to email, but please upload them only when ready to
submit electronically in Section E. Instructions in Section A say uploading documents and saving the Draft Document
before submitting may cause errors when resuming.
Item#9 (NOI Certification Form)—Working form is attached. Complete form, Print, sign, and then upload pdf for Item
#9. Ink signature required. Electronic signatures will NOT be accepted. In addition,you'll need to mail the original
signed hard copy of the NOI Certification Form to the address on the form.
Click Next button to move to Section E.
Section E:
After completing Section D and uploading the documents, review items and check the boxes. Then click on Sign button,
and then click the Submit button.
Payment:
After submitted e-NOI is reviewed and approved by NCDEQ,you'll receive instructions on making required payment. Do
not make payment until e-NOI is approved. Required payment is$120.00, and believe can make payment with credit
card.
Thank you.
** CAUTION: External email. Do not click links or open attachments unless sender is verified. Send all
suspicious email as an attachment to [e-mail] **
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