NCS000410_MS4 Annual Report Upload Record (2022-23 FY)_20230829

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit MSa Annual R... by Anonymous User 8/30/2023 10:19:15 AM (Start)

DEQ Report . . . .
For questions about submitting MS4 Annual Reports,contact Isaiah Reed at [e-mail]
MS4 Permittee Name*
Please choose the Town or City
Clemmons
Municipal Separate Storm Sewer System(MS4)
Permit No.* Annual Report Fiscal/Calendar Year
NCS000410 2022-23 FY
This field will fill automatically based on choice above. Fiscal Year is 1 Jul-30 Jun
Implementation Status of the Stormwater Program*
Please describe summary of implementation and compliance status.
The Village of Clemmons current approved SWMP went into effectJuly 14,2021 from NCDENR,is in compliance with the State of INC.The Village
of Clemmons is currently starting Year 3 of their current MS4 permit as of July 14,2023.
The minimum control measures for each measure is fully implemented with each year's description/goals within our template as presented.
Are there any proposed changes/revisions to the Stormwater Program?*
Include revisions to assessment of controls and any fiscal analysis revisions.Note:Proposed changes shall be submitted as part of a revised
Stormwater Management Plan(SWMP).
No changes have been made to the current MS4 Permit for the Village of Clemmons.
Annual expenditures for Report period* Annual budget for year following Report period*
$2,106,444.09 $2,791,425.00
Does the submitted document include a summary of data accumulated throughout the reporting year?*
Yes
No
Audited during report year
Does the submitted document include a summary of the number and type of enforcement actions, inspections,and Public
Education Programs conducted as identified in the SWMP?
Yes
No
Audited during report year
Does the submitted document include any identification of water quality improvements or degradation, including monitoring
*
data?
Yes
No
Audited during report year
N/A(May not apply for all Phase II MS4s)
The following certification must be included with your Annual Report and signed/dated in accordance with permit requirements:
"I certify by my signature below,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."
File Upload*
Please upload up to three(3)Annual Report document(s)below.
VOC_Stormwater Expenditures and Current Budget_24.pdf 342.69KB
2023_NCS000410_Clemmons Annual Self Assessment Template Report_20220714.pdf 129.72KB
PDF only(no larger than 100 MB each)
By checking the box and signing box below,I certify that:
• I have given true,accurate,and complete information on this form and in the uploaded Annual Report document(s);
• I agree that submission of this MS4 Annual Report Upload form is a"transaction"subject to Chapter 66,Article 40 of the NC General
Statutes(the"Uniform Electronic Transactions Act');
• I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the INC General Statutes(the"Uniform
Electronic Transactions Act');
• I understand that an electronic signature on this upload form has the same legal effect and can be enforced in the same way as a written
signature;
• I intend to electronically sign and submit this MS4 Annual Report Upload form;AND
• I have the authority to submit this Annual Report on behalf of this MS4 Permittee.
9 Signature*
Full Name*
Emily Harrison
Name of person submitting this form.
Title* Organization
Stormwater Technician II Village of Clemmons
Title of person submitting this form.
Phone Number*
336-766-9170
Phone number where we can reach you.
E-mail*
[e-mail]
You will receive an email confirmation of this submission.
Date
2023-08-30
North Carolina General Statute 143-215.6B(i)provides that:
Any person who knowingly makes any false statement,representation,or certification in any application,record,report,plan,or other document filed or required to
be maintained under this Article or a rule implementing this Article;or who knowingly makes a false statement of a material fact in a rulemaking proceeding or

contested case under this Article;or who falsifies,tampers with,or knowingly renders inaccurate any recording or monitoring device or method required to be
operated or maintained under this Article or rules of the Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).