NCC233001_NOI Signed Certification_20231006

Print this form, complete, scan and upload to the electronk NOI
Then, mail the original form to the NC DE MI R Stormwater Program (with $ 100 check if paying by check) at.
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 6*. floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL 1 HIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPI.[IF.
THE FORM YOU MAIL MUST BE COMPI l i E n WITH AN ORIGINAL SIGNATURE ' DIGITAL) (40 ('FR 122•221
Per NC General Statute 143-215.6B (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 ($10,060.
Under penalty of law, I certify that (check all boxes to indicate your agreement)
ei I am the person responsible for the construction activities of this protect, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Q 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.
0 I will abide by all conditions of the and the approved Erosion and Sediment Control
Plan.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the , I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0 I hereby request coverage under the 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.
Project Name (must match Ala): Storyhill Church
Specific Lot Numbers (must match Alb): Pin # as shown on Al C 00324183, 00324107
Permittee (must match 81): Storyhill Church
Legally Responsible Person (must match 82 & 83): Michael Flake
Title of Legally Responsible Person (must match 83b): Pastor
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 9013367148
10
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Signature of Legally Responsible Person or Authorized 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 a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 permit.