NCC191466_NOI Signed Certification_20190821

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Prink this form, complete, scan and upload to the electronic NOS.
Then, mail the original foam 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, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC Genera! Statute 143-215.6B (i), any person who knowingly makes crnyfalse statement, representation,
or certification in and application, record, report, plan, or other documentfiled or required to be maintained
under this article or a rule implementing this Article ... shall be gull y of a Class 2 mrsdemeartor which may
include cr fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, ! certify that (check all boxes to indicate your agreement):
Yr I am the person responsibie for the construction activities of this project, for satisfying the
requirements of this Dermit, and for any civil or criminal QenaCties incurred due to violations of this
permit.
C� The infirm
complete b
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ation submitted in this NCI is, to the best of my knowledge and belief, true, accurate, and
aced on my inquiry of the person or persons who manage the system, or those persons
arrecziy responsible for gathering the information.
Be I will abide by all conditions of the NCGO10000 General Perm
Sediment Control Plan.
it and the approved Erosion and
Q" If the approved Erosion and Sediment Control Plan is not compliant with Part !I (Stormwater Pollution
Prevention Phan) of the.NCGO10000 General Permit. I will nonetheless ensure that ail conditions of
Part fl of the permit are met on the project at all times..
1E I hereby request coverage under the NCG010000 general Permit and understand that �o�era e under
g
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:
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Title of Legally Responsible Person:
Signature:
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 NCGOIOOOO permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.