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HomeMy WebLinkAboutNCS000393_Dallas Permit Application_20210113DEQ NPDES MS4 Permit Renewal Application Form National Polluant 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 Current Permit No. NCS 000393 MS4 Name TOWN OF DALLAS Owner Name* TOWN OF DALLAS MARIA STROUPE Owner Title TOWN MANAGER Street Address 210 NORTH HOLLAND ST CITY State Zip Code DALLAS N.C. 28034 Phone Number 704 9223176 E-mail Address mstroupe@dallasnc.net * The owner must be a principal executive officer or ranking elected official for the city/town/entity that awns/operates the permitted M54. Any permit enforcement actions will be sent to the owner on record. Part II: Primary Contact** Contact Name Bill Trudnak Contact Title Public Works Director Employer TOWN OF DALLAS Street Address 700 E Ferguson St City, State, Zip Dallas, NC 28034 Phone Number 704-922-9961 E-mail Address b4r•ujnak0—dal)c5✓cc. ne "The ne primary contact is the responsible party who will oversee the day-to-day permit compliance and Storm water Management Program implementation. With the exception of enforcement actions, permit communicatlons originating from NCDEQ will be sent to the primary contact and will be copied to the other contacts listed below. Part III: Other Contacts Contact Name ZACK FOREMAN E-mail Address zforeman@dallasnc.net Contact Name E-mail Address 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 renewal application. The Draft SWMP must be in the current NCDEQ SWMP Template format and shall include all required information in order for the permit renewal application to be considered complete. Page 1 of 2 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, including the possibility of fines and imprisonment for knowing violations. I am also aware that incomplete permit renewal applications, inclusive of the required Draft SWMP, will not be processed and will be returned to the permittee. ❑ I am a ranking elected official for the permitted MS4. ® I am a principal executive officer for the permitted MS4. 0 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 specific individual having overall responsibility for the stormwater permit. ❑ A specific position having overall responsibility for the stormwater permit. Signature:* Print Name: MARIA STROUPE Title: TOWN MANAGER Signed this ^12_ day of 20_21 . * Please note that an original signature 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 PART 2: 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, including the possibility of Rues and imprisonment for knowing violations. I am also aware that the contents of this document shall become an enforceable part of the NPDES MS4 Permit, and that both the Division and the Environmental Protection Agency have NPDES MS4 Permit compliance and enforcement authority. ❑ lama ranking elected official. X I am a principal executive officer for the permitted MS4. ❑ I am a duly authorized representative for the permitted M84 and have attached the authorization made in writing by a principal executive officer or ranking elected official which specifies me as (check one): ❑ A specific individual having overall responsibility for storinwater matters. ❑ A specific position having overall responsibility for storinwater matters. Signature: Print Name: Maria Stroatpe Title: Town Manager Signed this /d-day of rnvu2020 . oJo4�l DRAFT NCS000393 SWMP Town of Dallas November 12, 2019 Page 2