NCC200329_NOI Signed Certification_20200124

Print this form, complete, scan and upload to the electronic NOI.
en, 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, 6ch Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
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 ($10,000).
Under penalty of law, 1 certify that (check all boxes to indicate your agreement):
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.
j I will abide by all conditions of the and the approved Erosion and Sediment
Control Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the , 1 will nonetheless ensure that all conditions -of
Part 11 of the permit are met on the project at all times.
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.
Name of Project: tAew 1`�Slc�a� P��S� Lhvrck
Legally Responsible Organizational Entity: New Trinity Missionary Baptist Church
Legally Responsible Person: Mike Sims
Title of
ble Person: Deacon
*Signature: rf d,&A �,, ti Date: / // 3 ) & -)-&
*Print Name and Title of Signed if Authorized Individual
Differs from Permittee: N/A
Phone Number: 919-606-5012
* 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.