NCS000428_Burlington Permit Renewal Application_20220518

City Manager/Mayor - Signature Request Form
This form is required For an document ret uestin asi nature from the City Manager or Mayor
The purpose is to ensure adequate internal review has been received and the content provided is accurate and appropriate to
meet the mission of applicable Departments within the City of Burlington.
Title and Type of Document: NPDES MS4 Permit Application Form
Department: Contact Name & Phone►#:
Water Resources - Stormwater Division Amy Barber 336.214.4058
Scope of Services:
N/A
Statement of Need:
The City is required to submit the NPDES MS4 Permit Application Form to NC DEQ to renew the
City's 5-year NPDES Stormwater Permit. The current permit expires in 2022.
BUDGET ACCOUNT CODE: N/A
Yes
No
N/A
BUDGET APPROVAL - Is this item already budgeted?
X
Certificate Of Insurance - Current & Attached
X
If the contract provides services in a more cost effective manner than City forces, please explain.
N/A
Document Deadline: Provide a date if this document is time sensitive:
05/13/2022 Dates & Initials (Acceptable)
Circulate all documents to the following Departments ONLY if hand written.
Staff requesting signature is responsible for tracking & providing request form to
Administration. When submitted to City Manager for signature, document must be in Date Date
final form. Received Forwarded Initials
Department Head: Bob Patterson REQUIRED)
I have reviewed this document and have satisfied myself that it is fair and justified from the
City's point of view. (Initials from staff "on behalf of are not acceptable; must be actual Dept
0
Head.)
Staff Member Name & Contact #: Amy Barber [phone]
This document has been approved by the Department Head -
Any questions about the document, contact me at the number Urovided.
Legal Review: City Attorney - David Huffman
This document has been reviewed and meets legal requirements.
Finance Review: Finance & Risk Management - Peggy Reece
Insurance: The C01 meets the requirements of this contract.
_
Budget- This contract includes the pre -audit statement and is in compliance with relevant
financial regulations.
Purchasing Review: Purchasing Manager - Sonjia Cross
These services or goods have been properly procured according to all current N.C.G.S.
City Manager - David Cheek
Mayor Signature Required or Needed:
(If Required)- City Clerk (Attest, Seal) - Deputy City Cleric (Notarize, Witness)
Version 12/2/21 City Council Meeting (Action)Date; If appllcable:

NPDES MS4 Permit Application Form
�D-0 Q�-!,"i' 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 NCS
Current Permit No,
NCS000428
MS4 Name
City of Burlington
Owner Name*
James B. Butler
Owner Title
Mayor
Street Address
425 S. Lexington Ave.
City,State Zip
Burlington, NC 27217
Phone Number
[phone]
E-mail Address
[e-mail]
* The owner must be a principal executive offlGer or ranking elected offcial far 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
Amy Barber
Contact Title
Stormwater Manager
EmQtqyer __City
of Burlington
Street Address
1302 Belmont St.
City' State, Zip _
Burlington, NC 27215
Phone Number
[phone]
E-mail Address
[e-mail]
** The primary contact is the responsible party Wvha Will oversee the da}- to -day permit cnmplfance 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 Bob Patterson
E-mail Address [e-mail]
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 having overall responsibility for the stormwater permit.
Signature:*
Print Name:
Title: I rl-1 0- l 0 r
Signed this 17 day of 20
* Please note that an original signature is required on this form, any r r;[ i�td supp/emental 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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