NCC240459_NOI Signed Certification_20240227

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, maul the original form to the NC DEMLR Stormwater Program (with $120 check if paying by check)
at:
Division of Energy, Mineral& Land Resources Stormwater Program
' 512 N.Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM HOU MAIL MUST BF COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.221
Per NC General Sttiltute 143-215.6E(0), 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 i plementing this Article. . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thous d dollars($10,000).
Under penalty of I w, I certify that (check all boxes to indicate your agreement):
O I am the p rson 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 foi
gathering the information.
Z I will abid oy all conditions of the N1GO10000 General Permit and the approved Erosion and Sediment Control
Plan.
p✓ if the app oved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Preventio Plan)of the NCG010000 General Permit. I will nonetheless ensure that all conditions of Part II of the
permit ar met on the project at all times.
❑✓ I hereby rdquest coverage under the NCG010000 General Permit and understand that coverage under this
permit wil constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name(must match Ala): The Redeemed Christian Church of God Victory Temple
Specific Lot Nu nbers(must match Alb): N/A
Permittee (mu4t match 81): Adebisi Oshikoya
Legally Responsible Person(must match 82& 83): Adebisi Oshikoya
Title of Legally Responsible Person(must match 83b): Pastor
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person: N/A
Phone Numbei': ( 919 ) 696 - 4779
A-AcLib-e.54 a-i(512-1-1--
Signature of Legally Responsible son or Authorized Individual Date
lf* IMPORTANT NOT : This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a presiden,secretory, treasurer,or vice president, or o manager that is authorized in accordance with Port IV,Section 8,
Item(6)of the NC 010000 permit.