NCC222749_NOI Signed Certification_20220803

NCGO1 Notice of Intent (N01) Certification Form
Directions'.
Print this form'. complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $1,00 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street., 61' Floor (Office 640K)
1612 Mail Service Center
Raleigh,, NC 27699-161.2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly rakes any false statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article or cr rule implementing this Article ... shall be guilty of a Class 2 misdernearrQr which may
i »cfude afine not to exceed yen thousand dollors; ($10,000).
Under penalty of haw, I 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 dui to violations of this
permit,,
!� The information submitted in this N01 is, to the best of my kno-wledge 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 iniormation.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
XJ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan} of the
NCG010000Perrrfit.
.,
I will nonetheless ensure that all conditions of
Park 11 of the permit are
met an the
project
at all times.
YJ I hereby request coverage under the NCGOI.0000 General 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 of Project: Sneads Ferry Presbyterian Church
Legally Responsible Organizationai Entity.- Sneads Ferry P.resbyterian Church, Inc.
Legally Responsible Persom. Barbara Donaldson �...�.._.___-�__.�..__�......�...�,
Title of Legally Respon5ible Person:
Si u e
Clerk of Session
*print erne and Title of Signed if Authorized
Individual Differs from Permittee.,
Phone Number: 703-336-2087
* IMPORTANT
NO : This form must be signed by a responsible
corporate officer
that ovens or operates the
construction
activity, such as a president, secretary
1 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 informatl"6n on signatory iequ7ieliiefft.7g see Part IV, Section B., item (6) of the NCGO10000 permit.