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HomeMy WebLinkAbout04_City of Burlington Renewal Application Signed by MayorCity 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 (336)214-4058 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 (336)222-5091 E-mail Address JButier@burlingtonnc.gov * 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 (336)222-5091 E-mail Address abarber@burlingtonnc.gov ** 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 Bpatterson@burlingtonnc.gov 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. Page 1 of 2 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 Page 2of2