NCS000454_Stallings MS4 Permit Application Form_20220427

^BEQ^WfWWINA
OWrtnitftttf tm*tnneul Oiumy'
NPDES MS4 PermitApplication Form
National Pollutant Discharge Elimination System (NPDES)
Municipal Separate Storm Sewer System (MS4)
Please complete the information below and submit this form along with the required supplemental information
to the address indicated.
Part I:Permittee Information
**The primary contact is the responsible party who will oversee the day-to-day permit compliance and
Stormwater Management Program implementation.With the exception of enforcement actions,permit
communications originating from NCDEQ will be sent to the pn'mary contact and will be copied to the other
contacts listed below.
Part III:Other Contacts
Part IV:Required Supplemental Information
Submit one (1)hard copy and one (1)electronic copy of a Draft Stormwater Management Plan (SWMP)
with this permit application.The Draft SWMP must be in the current NCDEQ SWMP Template format
and shall indude all required information in order for the permit renewal application to be considered
complete.
Page 1 of 2
Current Permit No.NCS
MS4 Name Town of Stallings
Owner Name*Wyatt Dunn
OwnerTitle Mayor
Street Address 315Stallings Road
City,State,Zip Stallings.NC 28104
Phone Number 704-821-8557
E-mail Address
*The owner must be a principal executive officer or ranking elected official for the city/town/entity that
owns/operates the permitted MS4,Anyperm/t enforcement actions will be sent to the owner on record,
Part II:Primary Contact**
Contact Name Alex Sewell
Contact Title Town Manaaer
Employer Town of Stallings
Street Address 315Stallings Road
City,State,Zip Stallings,NC 28104
Phone Number 704-821-8557
E-mail Address [e-mail]
Contact Name Bo Coneriy,P.E.,CFM
E-mail Address [e-mail]
Contact Name Justin Russell
E-mail Address [e-mail]
Part V:Certification
By my signature below I hereby certify,under penalty of law,that this document and all attachments
were prepared under my direction or supervision in accordance with a system designed to assure that
qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of
the person or persons who manage the system,or those persons directly responsible for gathering the
information,the information submitted is,to the best of my knowledge and belief,true,accurate,and
complete.
I am aware that there are significant penalties for submitting false information,induding the possibility
of fines and imprisonment for knowing violations.I am also aware that incomplete permit renewal
applications,indusive ofthe required Draft SWMP,will not be processed and will be returned to the
permittee.
K]I am a ranking elected offidal for the permitted MS4.
D I am a principal executive officer for the permitted MS4.
D I am a duly authorized representative for the permitted MS4 and have attached the authorization
made in writing by the permit owner listed in Part I of this application,which specifies me as (check
one):
a A specific individual having overall responsibility for the stormwater permit.
O A specific position having overall responsibility for the stormwater permit.
*Please note thatan oriainal sianature is required on this form,any required supplemental information,and any
representative authorization.Photocopies cannot be accepted.
Return this completed form along with the required supplemental information to:
DEQ-DEMLR Stormwater Program
Attn:MS4 Permitting
1612 Mail Service Center
Raleigh,NC 27699-1612
Page 2 of 2
Signature:*
Print Name:Wyatt Dunn
Title:Mayor
Signed this ^day of 20t^