NCS000427_Permit Application_2016

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SWU-264 June 17, 2015
NPDES STORMWATER PERMIT RENEWAL APPLICATION FORM

This application form is for use by Local Governments 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 LOCAL GOVERNMENT, PERMIT NUMBER, AND EXPIRATION DATE

Name of Local Government

Town of Cary
Permit Number

NCS000427
Expiration Date

11/30/2016

II. CO-PERMIT APPLICATION STATUS INFORMATION
(Complete this section only if 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-permittees?
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

NPDES RPE Stormwater Permit Application

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SWU-264 June 17, 2015
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 board action
delegating permit authority to this person/position must be provided.

a. Name of person to which permit
authority has been delegated

b. Title/position of person above

V. SIGNING OFFICIAL’S STATEMENT

If authority for the NPDES stormwater permit has been appropriately delegated through
board action 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
Name Michael J. Bajorek
Title Interim Town Manager
Street Address 316 North Academy Street
PO Box 8005
City Cary
State North Carolina
Zip 27513
Telephone [phone]
E-Mail [e-mail]

VI. LOCAL GOVERNMENT 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 Charles E. Brown
b. Title Stormwater Program Analyst
c. Street Address 316 North Academy Street
d. PO Box 8005
e. City Cary
f. State North Carolina
g. Zip 27513
h. Telephone Number 19-469-4038
j. E-Mail Address [e-mail]
NPDES RPE Stormwater Permit Application

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SWU-264 June 17, 2015
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. Population and Estimated Growth Rate
2. Jurisdictional Area
3. Describe Stormwater Conveyance System
4. Estimated Land Use
5. Identify the Receiving Streams
6. Identify TMDLs (if applicable)
7. Identify impaired streams, likely sources, and existing programs that address the impairment
(if applicable)
8. List any existing water quality programs
9. Identify and describe any partnerships and/or inter-local agreements
10. Describe any state programs
11. Identify any other entity that the regulated public entity relies on to implement or manage its
stormwater program.
12. Identify points of contacts
13. Describe the public education and outreach program
14. Describe the public involvement and participation program.
15. Describe the Illicit Discharge Detection and Elimination Program.
16. Describe the post-construction stormwater program
Describe practices to inspect and maintain municipally-owned facilities
17. Describe practices to inspect and maintain structural stormwater control devices
18. Describe practices to reduce polluted stormwater runoff from municipally-owned streets,
roads, and public parking lots, piped and vegetative conveyances, manholes, cleanouts, drop
inlets, and drainage structures.
19. Describe any training programs for municipal staff.
20. Describe spill response procedures for those at Municipally Owned and/or Operated Facilities
as well as those in the public right-of-way.