NCC191723_NOI Signed Certification_20190905

NCGOJ W)Aice of Intent (NOI) Certificatiari Forin
Directions:
M,R=
Then, mail the original form 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, 6" Floor
1612 Mail Service Center
1 11 — —1 (1/, trly pers#n 77777pi [VIAlke-S-1-fln -.5- — rctnd,M77 ion,
or certification in any application, record, report, pion, or other documentfiled 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 afine not to exceed ten thousand dollars ($10,000).
Under penalty of law, i certify that (check all boxes to indicate your agreerl"lent):
I am the person responsible for the construction activities of this project, for satisfy irg the
requirements of this permit, and for any dO or criminal penalties incurred due to violations of this
perrnit,
'The inforr'nation submitted in this NOI is, to the best of rriy knowledge and belief, true, accurate® and
complete based on my inquiry of the person or persons who manage the systern, or those persons
directly responsiWe for gathering the information.
I will abide by all conditions of the rQCGO 10000 [DerrnH, and the approved Erosion and
Sediment Control Plan.
Si if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Storn'-rwater Pollution
Prevention Plan) of the NI(IC Ol0c,"KJO wHl nonetheless ensure that aH conditions of
Part li of the perrnit are rnet on the project at all times.
i hereby request coverage under the r,4C1G(').1 ()Qr,)Q Gf,,i miryd 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,
tional Entity:
r /")f'
ONVAI
Signature:
I
*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.