NCC191659_NOI Signed Certification_20190829

NCG01 Notice of Intent (N00) Certification Form
Directions:
Division of Energy, Mineral & Land Resources StmrmwaterPmgram
512N.Salisbury Street, 6mFioor
1613Mail Service Center
Raleigh, MC27G99-1G13
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article or a rule implementing this Article.. . sholl be guilty of a Class 2 misdemeanor which may
include afine not to exceed ten thousand dollars ($10,000).
Uncle kyoflaw, | certify that (check all boxes toindicate your agneemen1>:
^� 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.
_/
�� 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.
� �
�� | will abide byall conditions ofthe and the approved Erosion and
Sediment Control Plan,
Py If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) nfthe 1will nonetheless ensure that all conditions of
the permit are met onthe project aiall times.
0 | hereby request coverage under the NCG010000 Gene4 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,
�
Name ofPo�d e:
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Signature:
Date:
*IMPORTANTNOTE: 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 NCGO1 0000 permit,