NCC190095_NOI Signed Certification_20190424

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NCGO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 14.3-215.613(i), any person who knowingly makes arlyfulse statement, representation,
or certification in any application, record, report, plan, or other docu entfiledmnequired tobemaintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include o fine not bz exceed ten thousand dollars/$10,000/.
Under penalty of law, | certify that (check all four boxes to indicate your agreement):
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I arn 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.
Q0 The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, and
complete based onmy inquiry ofthe person or persons who manage the system, orthose persons
directly responsible for gathering the information.
| will abide by all conditions nfthe NCG010000 General Permit 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) ofthe en' | will nonethe|eoensure that all conditions of
Pa� || nf the permit are met ontheprojectat all times.
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�� | hereby request coverage under the NCGO.10000 General Permit and understand that coverage under
this permit will constitute the permit requirernents for the discharge(s) and is enforceable in the
same manner asan individual permit.
New Direction church
Legally Responsible Organizational Entity:
watthew Galloway
* Legally Responsible Person:
m= Apr 12, 2019 | I0:39:3I
Signature: Date:
* IMPORTANT NOTE: Thisform 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.