NCS000393_Dallas Permit Application_20210113

DEQ
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
[e-mail]
* 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
[e-mail]
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