NCC191694_NOI Signed Certification_20190904

Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division ofEnergy, Mineral & Land Resources6tonnwater Program
512 N. Salisbury Street, 6m Floor
1612Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute243-225.6B (i), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article morule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$1(I00U/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
12 1 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.
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�� 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 ufthe NCGO10000 General li and the approved Erosion and
Sediment Control Plan.
a"'If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGOI.0000 General Permit, | will nonetheless ensure that all conditions of
Part Uofthe permit are met onthe project atall times.
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my | hereby request coverage under the Genera ' I Permit and undentandthat coverage under
this permit will constitute the permit nequi/ementsfor the discharge(s) and isenforceable inthe
same manner asanindividual permit.
Name ofProject: Glad Acres- Phase 1
Legally Responsible Organizational Entity: A tL,-Le_," Hok"e,� e,6- c
*Legally Responsible Person: n
Title of Legally Responsible Person: _Ael a"?
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Signature: —Date: 0/1?
*IMPORTANTNOTE: This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such osopresident, secretary, treasurer, n,vice president, nromanager that is
authorized /naccordance with Part IV, Section fLItem (6) ofthe N(GJ71DO0Opermit.
For more information nnsignatory requirements, see Part IV, Section 8,Item (6)ofthe /V[601DO00permit.