NCS000240_Renewal Application_20230323

- NPDES MS4 Permit Renewal Application Form
National Pollutant Discharge Elimination System (NPDES)
t "'""F'�k`"`"' Municipal Separate Storm Sewer System (MS4)
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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. NCS000240
MS4 Name City of Charlotte
Owner Name* Marcus D. Jones
Owner Title City Manager
Street Address 600 East 4th Street
City, State, Zip Charlotte, NC 28202
Phone Number 704-336-2403
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 MS4. Any permit enforcement actions will be sent to the owner on record.
Part II: Primary Contact"
Contact Name Craig Miller
Contact Title NPDES Permit Supervisor
Employer City of Charlotte
Street Address 600 East 4th Street
City, State, Zip Charlotte, NC 28202
Phone Number 704-336-7605
E-mail Address I [e-mail]
** The primary contact is the responsible party who will oversee the day-to-day permit compliance 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 Jordan Miller
E-mail Address Jordan.Miller@charlottenc. ov
Contact Name Mike Davis
E-mail Address [e-mail]
Contact Name Angela Charles
E-mail Address [e-mail]
Part IV: Required Supplemental Information
None. Currently, submittal of a draft Stormwater Management Plan (SWMP) with an NPDES MS4
Permit Renewal Application is not required for NPDES MS4 Phase 1 designated cities in North Carolina.
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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.
0 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):
0 A specific individual having overall responsibility for the stormwater permit.
❑ A specific position having overall responsibility for the stormwater permit.
Signature:*
Print Name: Michael A. Davis, PE
Title: Director of Storm Water Services
Signed this 2 ' day of March , 2023.
*Please note that an original 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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NC Department of Environmental Quality
°�. Division of Energy, Mineral and Land Resources
NORTH CAR01 INA
E'nvironmcntul Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
=> This form shall be used to delegate signature authority from the permit Owner(Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit(such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
i
The permit Owner is the legal entity to which/whom a permit has been issued, and may be an individual
or an organization such as a company orgovernment agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22, summarized
I below:
I' For a corporation, the Responsible Official shall be a president, secretary, treasurer, or vice-
president in charge of a principal business function, or-another individual who performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
i facilities who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the
proprietor, respectively;or '
I
j0 For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer[City/County Manager]or ranking elected official[Mayor].
i
Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions. J
Permittee: City of Charlotte
i
Permit Number: NCS000240
Responsible Official Title: Marcus D. Jones (City Manager)
Email Address: [e-mail] Phone: [phone]
Mailing Address: 600 East 4th Street
City: Charlotte State: NC Zip: 128202 '
J
Stormwater Delegation of Signature Authority Form
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A. Persons to Receive Signatory Authority
The signatures of the persons fisted below indicates their acceptance of signatory authority.
Delegated Party Name: Michael A.Davis (Signatory Authority Granted for all NPDES MS4 Permit Matters)
Delegated Party Title; Director of Storm Water Services_
Delegated Party Organization: City of Charlotte-Storm Water Services v
Email Address: [e-mail] I Phone: [phone]
Mailing Address: 600 East 4th Street
City: Charlotte I State; NC I Zip: 28202
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date: 4 21 202'Z
Delegated Party Name: Marc D.Recktenwald (Signatory Authority Granted for MS4 SW Management Plans and Annual Reports Only)
Delegated Party Title: Surface Water Quality and Environmental Permitting Program Manager
{ Delegated Party Organization: City of Charlotte-Storm Water Services
Email Address: [e-mail] I Phone: [phone]
Mailing Address: 600 East 4th Street
City: Charlotte State: NC I Zip: 28202
} Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
I
Delegated Party Name:
Delegated Party Title: '
Delegated Party Organization:
Email Address: Phone:
Mailing_Address:
City: State: Zip:
Signature of Delegated Party indicating j
acceptance of Signatory Authority: '
Date: C
_ f
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address: Phone:
Mailing Address:
City: I State: Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority: j
Date:
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Stormwater Permit Delegation of Signatory Authority Form
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B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Marcus D.Jones (printed name),
have the authority to enter into this Agreement for
City of Charlotte (Owner/Organization Name).
request that the DEMLR Stormwater Program include the persons listed in Part A of this form
signatory authority for the above-named permit. I
I acknowledge that I, and the persons listed in Part A of this form work at/for my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Marcus D.Jones (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I th R sible Official.
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s o sible Official Si ture
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Stormwater Permit Delegation of Signatory Authority Form
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