NCS000290_Camp Lejeune 2015 Permit Application Form_20150101

State of North Carolina
Department of Environment & Natural Resources
Division of Energy, Mineral, and land Resources
OFFIC USE ONLY
Date Rec'd
Fee
Paid
Permit
Number
NPDES STORMWATER PERMIT APPLICATION FORM
This application form is for DoD seeking NPDES stormwater permit coverage for Regulated Public Entities (RPE)
pursuant to Title 15A North Carolina Administrative Code 2H .0126. A complete application package includes
this form and one copy of a Narrative of The Stormwater Management Program. The required Narrative of The
Stormwater Management Program is described in Section VII of this form.
I. NAME OF PUBLIC ENTITY SEEKING PERMIT COVERAGE
Name of DoD Facility Seeking Permit Marine Corps Installations East -Marine Corps Base
Coverage Camp Lejeune (MCIEAST-MCB CAMLEJ)
II. CO -PERMIT APPLICATION STATUS INFORMATION
(Complete this section only it co -permitting)
a. Do you intend to co -permit with another regulated public
entity? ❑ Yes ® No
b. If yes, name of regulated public entity
c. If yes, have legal agreements been finalized between the co-
oermittees? I ❑ Yes ❑ No
III. RELIANCE ON ANOTHER ENTITY TO SATISFY ONE OR MORE OF YOUR PERMIT OBLIGATIONS (If more than
one, attach additional sheets)
a. Do you intend that another entity perform one or more of your
permit obligations?
❑Yes ®No
b. If yes, identify each entity and the element they will be implementing
• Name of Entity
• Element they will implement
• Contact Person
• Contact Address
• Contact Telephone Number
C. Are legal agreements in place to establish responsibilities?
❑Yes ®No
IV. DELEGATION OF AUTHORITY (OPTIONAL)
The signing official may delegate permit implementation authority to an appropriate staff member. This
delegation must name a specific person, their title/position. Documentation of action delegating permit
authority to this person/position must be provided,
has been
b: Title/position of person above
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NPDES RPE Stormwater Permit Application
V. SIGNING OFFICIAL'S STATEMENT
If authority for the NPDES stormwater permit has been appropriately delegated and documented in
this permit application, the person/position listed in Section IV above may sign the official statement
below.
I 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,
including the possibility of fines and imprisonment for knowing violations.
Signature
Lj Gl� WN
Name
Joh R Townson
Title
Director, Environmental Management Division, G-F
Street Address
Commanding General, MCIEAST-MCB CAMLEJ
Building 12, Post Lane
PO Box
PSC 20005
City
Camp Lejeune
State
North Carolina
Zip
28542-0005
Telephone
910-451-2526
E-Mail
[e-mail]
VI. CONTACT INFORMATION
Provide the following information for the person/position that will be responsible for day to day
implementation and oversight of the stormwater program.
a.
Name of Contact Person
Michael Taylor
b.
Title
Stormwater Program Manager, EAS, EMD
c.
Street Address
Same as above
d.
PO Box
e.
City
f.
State
g.
Zip
h.
Telephone Number
910-451-9657
i.
E-Mail Address
[e-mail]
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NIRIDES RPE Stormwater Permit Application
VII. NARRATIVE STORMWATER MANAGEMENT PROGRAM
Attach one copy of a narrative describing the stormwater management program. The report must be
presented in the following order.
1. Describe Stormwater Conveyance System
2, Estimated Land Use
3. Identify the Receiving Streams
4, Identify TMDLs (if applicable)
5. Identify impaired streams, likely sources, and existing programs that address the impairment (if
applicable)
6. Identify points of contacts
7. Describe the public education and outreach program
8. Describe the public involvement and participation program.
9. Describe the Illicit Discharge Detection and Elimination Program,
10. Describe the post -construction stormwater program
11. Describe practices to inspect and maintain structural stormwater control devices
12. Describe practices to reduce polluted stormwater runoff from streets, roads, and public parking lots,
piped and vegetative conveyances, manholes, cleanouts, drop inlets, and drainage structures.
13. Describe any training programs for staff.
14. Describe spill response procedures.
15. Describe practices to inspect and maintain "industrial activities" that have 1) vehicle maintenance
areas (including vehicle, mechanical repair, painting, fueling, lubrication, equipment cleaning
operation areas and like activities), 2) activity from Air Transportation including air transportation,
airports, and aircraft service and maintenance including: aircraft cleaning; aircraft servicing/repairing,
and aircraft maintenance shops (including aircraft and equipment rehabilitation, mechanical repairs,
painting, fueling, lubrication) and, 3) wastewater treatment facilities treating domestic sewage or any
other sewage sludge or wastewater treatment device or system, used in the storage, treatment,
recycling, and reclamation of sewage
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