NCC216393_NOI Signed Certification_20211115

N0001 Notice of intent (Na) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NCDEMLRaormwater Program (with $100 deck if paying by check) at:
Division of Energy, Mineral & Land Fbsouroesaormwater Program
512 N. S31isbury Greet, 6th Roor (Office 64019
1612 Mail Service Center
Raleigh, NC27699-1612
DONOTMAILTHISFORM ORPAYM9VTUN7ILYOURAPPUCA'iiONHASEEEVAOM7MASOOMPLEfE
THE FORM YOU MAIL MUST EEGOMRHmWITHANORIGINALSGNATURE (NOT DIGITAI.,1j4I] 722.22j
Per NCGeneral Satute 143-215.6E (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 thisArtide ... shall be guilty of a Oass 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10, 000).
Under penalty of law, I certify that (check all boxesto 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 violationsof this permit.
1� 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 personswho manage the system, or those personsdirectly responsible for
gathering the information.
1 I will abide by all conditions of the N03010000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Ran isnot compliant with Part 11 (aormwater Pollution
Prevention Plan) of the N03010000 General Permit, I will nonetheless ensure that of l conditions of Part 11 oft he
permit are met on the project at all times.
I hereby request coverage under the N00010000 General Permit and understand that coverage under this
permit will constitute the permit requi rements for t he di scharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala): MCA Track and Field
Specific Lot Numbers (must match Alb):
Legally lesponsible Organizational Entity (must match Ell): First Baptist Church of Indian Trail
Legally F;bsponsible Person (must match B2 & B3): Julie James
Title of Legally Pesponsible Person (must matchWb): Registered Agent
Name & Title of Signed if Authorized Individual
Differsfrom Legally Responsible Person:
Phone Number: 704-223-2255
ure of
ly Responsible Person or Authorized Individual
11/12/2021
Date
* IMPOKANTNOM 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, fiction B,
Item (6) of the NOG010000 permit.