NCS000400_Jamestown 2021 MS4 Renewal Application_20210706

� NPDES MS4 Permit Renewal Application Form
e:,�rDEQNational Pollutant Discharge Elimination System (NPDES)
«�-.1 Municipal Separate Storm Sewer System (MS4)
Please complete the information below and submit this form along with the required supple+at earn
to the address indicated.
Part I: Permittee Information
JUL 06 2021
Current Permit No.
ENR-1-AND QU,111T`/
NCS 000400
P,. Y. �Cra
MS4 Name
v i��t i! 18�
Town of Jamestown
Owner Name*
Matthew Johnson
Owner Title
Assistant Town Manager
Street Address
301 E. Main St.
City, State Zip
Jamestown, NC 27282
Phone Number
336-454-1138
E-mail Address
[e-mail]
* The owner must be a principal executive officer or ranking elected official for the city/town/entity that
owns/operates the permitted M54. Any permit enforcement actions will be sent to the owner on record.
Part II: Primary Contact**
Contact Name
Paul Blanchard
Contact Title
Public Services Director
Employer
Town of Jamestown
Street Address
301 E. Main St.
City, State, Zip
Jamestown, NC 27282
Phone Number
336-454-1138
E-mail Address
[e-mail]
** 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 primary contact and will be copied to the other
contacts listed below.
Part III: Other Contacts
Contact Name
Anna Haw luk
E-mail Address
[e-mail]
Contact Name
Katie Weiner
E-mail Address
kweiner amestown-nc. ov
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.
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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.
❑x I am a principal executive officer for the permitted MS4.
❑ 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:
Matthew Johnson
Title:
Assistant Town Manager
Signed this _29th_ day of June 2021_ .
* Please note that an on ina/ 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
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