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HomeMy WebLinkAboutNCS000564_Permit Application_20220712QEQ NPDES MS4 Permit Application 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 Current Permit No. NCS 000564 MS4 Name Town of Wendell Owner Name* Marvin Collins Owner Title Town Manager Street Address 15 E Fourth Street City, State, Zip Wendell NC, 27591 Phone Number 919) 365-4450 E-mail Address mcollins@townoAvendell.com * Theownermustbeaprincipalexecutiveofficerorrankinge%tedofficialforthe city/town/entitythat owns/operatesthepermittedMS4. Anypermitenforcementactionswillbesenttothe owneronrecord. Part II: Primary Contact** Contact Name Joseph Collins Contact Title Public Works Superintendent Employer Town of Wendell Street Address 15 E Fourth Street City, State, Zip Wendell NC, 27591 Phone Number (919)365-4822 EXT318 E-mail Address jcollins@townofivendell.com ** The primarycontactis the responsibleparty who will oversee the day-to-daypermitcompliance and StormwaterManagementProgramimplementation, With the exception of enforcementactlons,permit communicationsonginatingfrom NCDEQ willbesentto theprimarycontactand willbecopied to the other contacts listed below. Part III: Other Contacts Contact Name Brian Bray -Public Works Director E-mail Address bbray@townofwendell.com Contact Name Stephanie Smith -Assistant Town Manager E-mail Address ssmith@townoflvendell.cont 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 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. XI 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: MZ'5i�.v I N TEe Coc C_4 pi.4 a — Title: Qi ,Q v� Signed this day of 20 Z?_ *Please note thatanori inalsignatureisrequiredonthisform,anyrequiredsupplementalinformation,andany representative authorization. Photocopies cannot beaccepted. 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