NCS000455_Renewal Application_20230818

NPDES MS4 Permit Renewal Application Form
D National Pollutant Discharge Elimination System (NPDES)
Municipal$ M.S $y em (MS4)
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Please complete the information below and submit this form along with the requir�J s pleme �tion
to the address indicated. AUG 202 L `�� �o "r3
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Part I: Permittee Information tog
Asheville Regional Office 9LRS<o�m
Current Permit No. NCS S000455
MS4 Name Town of Oak Island r
Owner Name* David Kelly
Owner Title Town Manager
Street Address 4600 E. Oak Island Drive
City, State, Zip Oak Island, NC 28465Co
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Phone Number 920-201-8002 c� '
E-mail Address [e-mail] C) ` I
* 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 Rick Patterson
Contact Title Stormwater Administrator
Employer Town of oak Island
Street Address 4601 E. Oak Island Dr.
City, State, Zip Oak Island, NV 26465
Phone Number 910-933-4026
E-mail Address [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
E-mail Address
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 renewal 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: David Kelly
Title: Town Manager
Signed this 9th day of August,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