NCS000409_Belmont Permit Renewal Application_20210805

DNPDES MS4 Permit Application Form
FW 0 Vj National Pollutant Discharge Elimination System (NPDES)
mam—��' 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.
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MS4 Name
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Owner Name*
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Owner Title
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Street Address
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City,State Zip-�
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Phone Number
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E-mail Address
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* The owner must be a principal executive otter br ranking elected official for tlfe 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
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Contact Title
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Employer
Street Address
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Ci State Zip_Z
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Phone Number
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E-mail Address
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** The primary contact is the responsible pa who will oversee the d-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
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E-mail Address(Ofo\
V-1RAM{� Y
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 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.
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 havingverail responsibility for the stormwater permit.
Signature:*
Print Name:
Title:
C1 dJ c
Signed thisdayof 20�Z
* Please note that an ri in signature is required on this form, any required supplemental infonnahon, 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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