NCS000250_NCDOT Permit Renewal Application_20200221

NPDES Statewide MS4 Permit
Renewal Application Form
Please complete the information below and submit this form to the address indicated.
Part I: Permittee Information
Current Permit No.
NCS 000250
MS4 Name
North Carolina Department of Transportation
Owner Name*
James H. Tro don III until 2 29 2020 • Eric Bo ette effective 3/1 2020
Owner Title
Secretary of North Carolina Department of Transportation
Street Address
1501 Mail Service Center
City, State Zip
Raleigh, North Carolina 27699-1501
Phone Number
919-707-2800
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
Andrew McDaniel PE
Contact Title
Engineering Supervisor
Employer
North Carolina Department of Transportation — Hydraulics Unit
Street Address
1590 Mail Service Center
City, State Zip
Raleigh, North Carolina 27699-1501
Phone Number
919-707-6739
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
Dan O'Connor
E-mail Address
[e-mail]
Contact Name
Brian Lipscomb
E-mail Address
[e-mail]
Part IV: Required Supplemental Information
The permittee will be required to submit a permit renewal application supplement within one hundred
twenty (120) days of receiving the draft permit associated with this renewal application. The
supplemental information shall include one (1) hard copy and one (1) electronic copy of a Draft
Stormwater Management Plan (SWMP) which details specific actions, measurable goals,
implementation timelines and annual reporting metrics demonstrating compliance with the draft permit
requirements.
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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.
® 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 respp�sibilfor the stormwater permit.
� /\\
Signature:*
Print Name:
Jame H. Trod , III
Title:
Secr
a of N h Carolina Department of Trans ortation
Signed this 20th day of February, 2020.
* 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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