NCC250508_NOI Signed Certification_20250225

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,60 Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) 140 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 Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars(510,000).
Order penalty of law, I certify that(check all boxes to indicate your agreement):
!am the person responsible tor 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.
The information submitted in this NOI is,to the hest 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 NCC-9,1SDIGeneral Permit and the approved Erosion and Sediment Control
Plan
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
'g
Prevention Plan)of the NCGOIDDCQGeneral Permit, I will nonetheless ensure that all conditions of Part Il of the
permit arc met on the project at all times.
XI hereby request coverage under the NCGh10O00 General Pe!rn • 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.
arcs;eLI Name(must match Ala): 01)1C.A Ckerl L k 3
Specific Lot Numbers(must match Alb): �---F 3 Perm ittee (must match 81): Q•(2ilneti .h LLc
1 J.
Legally Responsible Person (must match R2 K 8.3): g<G,. p• I
Title of Legally Responsible Person(must match B3b): *h9S� 1 br
Print Name&Title of Signed if Authorized l r
Individual Differs from Legally Responsible Person:
Phone Number: Ct!l VI 3
1 •i1,ac
55Enature of Legally Responsible Person r uthoriz 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 o manager that is authorized in accordance with Port W.Section 8,
item IN of the NCGOI0000 permit