NCS000405_Gibsonville Permit Renewal Application_20210823

N
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 sul ormation
to the address indicated. \ ,,
Part I: Permittee Information
AUG 2 3 2021
Current Permit No.
NCS 000405 DE:NR-LAND QUALITY
MS4 Name
ST
Town of Gibsonville GERMITTING
Owner Name*
Ben Baxley
Owner Title
Town Manager
Street Address
129 West Main Street
City,State Zip
Gibsonville, NC 27249
Phone Number
336-449-4144
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 w/ll be sent to the owner on record.
Part II: Primary Contact**
Contact Name
Josh Johnson, PE
Contact Title
Stormwater Engineer
Employer
Alley, Williams, Carmen & King, Inc.
Street Address
740 Chapel Hill Rd.
City,State Zip
Burlington, NC 27216
Phone Number
336-226-5534
E-mail Address
[e-mail]
** The primary contact & the responsible party who will oversee the day-to-day permit compliance and
Stormwater Management Program Implementation. With the except/on 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
Phil Ross - Stormwater Coordinator
E-mail Address
[e-mail]
Contact Name
Rob Elliot - Public Works Director
E-mail Address
[e-mail]
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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It
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:*
&17�
Print Name:
Ben Baxley
Title:
Town Manager
�h I
Signed this t17 day of A l.j dusi Z 021
* Please note that an ori4ina/ 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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