NCS000564_Permit Application_20220712

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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 supplemental information
to the address indicated.
Part I: Permittee Information
Current Permit No.
NCS 000564
MS4 Name
Town of Wendell
Owner Name*
Marvin Collins
Owner Title
Town Manager
Street Address
15 E Fourth Street
City, State, Zip
Wendell NC, 27591
Phone Number
919) 365-4450
E-mail Address
[e-mail]
* Theownermustbeaprincipalexecutiveofficerorrankinge%tedofficialforthe city/town/entitythat
owns/operatesthepermittedMS4. Anypermitenforcementactionswillbesenttothe owneronrecord.
Part II: Primary Contact**
Contact Name
Joseph Collins
Contact Title
Public Works Superintendent
Employer
Town of Wendell
Street Address
15 E Fourth Street
City, State, Zip
Wendell NC, 27591
Phone Number
[phone] EXT318
E-mail Address
[e-mail]
** The primarycontactis the responsibleparty who will oversee the day-to-daypermitcompliance and
StormwaterManagementProgramimplementation, With the exception of enforcementactlons,permit
communicationsonginatingfrom NCDEQ willbesentto theprimarycontactand willbecopied to the other
contacts listed below.
Part III: Other Contacts
Contact Name
Brian Bray -Public Works Director
E-mail Address
[e-mail]
Contact Name
Stephanie Smith -Assistant Town Manager
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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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.
XI 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:
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Title:
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Signed this day of 20 Z?_
*Please note thatanori inalsignatureisrequiredonthisform,anyrequiredsupplementalinformation,andany
representative authorization. Photocopies cannot beaccepted.
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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