NCS000406_Renewal Application_20220804

Public Services
(� Stormwater Services
209 Coleman Drive
se PO Box 1810
Wilmington,NC 28402-1810
cinoe 910 343-4777
��T �T 910341-0099fax
� `%- .�� 1 0l V wilminglonnc.gov
NORTH CAROLINA Dial 711 TTYNoice
August 2, 2022
The City of Wilmington is pleased to provide a copy of our draft Stormwater
Management Plan (Permit# NCS000406) and MS4 Permit Application Form.
Please contact me with any questions you may have related to the plan.
Fredric.Royal(eilwilminotonnc.aov
RECEIVED
Sincerely----------�
Fredric Royal DEMLR-Stormwater Program
City of Wilmington
Stormwater Services Manager
910-341-5818
RECEIVED
SEP 0 7 207.?
LEWD QUALIi r 6Ei:ria�
Aqurrn

DEQ� NPDES MS4 Permit Application Form
�, National Pollutant Discharge Elimination System (NPDES)
�• ^-�-k9 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 0 O6
MS4 Name CIT-( or-
Owner Name* Tol� G41JVL�
c
Owner Title C IT'-1 p^D✓Jd G1Z p
Street Address /DZ N. T4410V
City, State Zip WIL'Milmr2mm , NG 2
Phone Number 910- 3¢1- 4658
E-mail Address Ol4 WwIt.MI wmptt4 ov
* The owner must be a principal executive officer or ranking elected official for 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 QED d4,
Contact Title lz
Employer CIT DF v4t 1 &
Street Address 209 C.M tJ VV1
City, State Zip 1 IN N Z8414
Phone Number - 66 1$
E-mail Address I 1:0Fmic. L®IFhVMI tJL.pipv
** 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 J1" tt414
E-mail Address J1M• 6 AI RJ MjU TW1J
Contact Name hlvrY riAr-
E-mail Address 1[)6 A tc.MWanvD)t IC• GOV
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 l �pp�idered�
complete. �ttGGtl�V E
SFP o 7 2022
Page 1 of 2 LAND QUALITY SECTION
ASHEVILLE

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.
VI 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: ��—
c�
Title:
c�
Su�*9
Signed this a�2�ay of 20a,
*Please note that an onainal 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 RECEIVED
, FP
LAND QUALITY SECTION
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