NCS000605_Hudson Permit Application_20201209

NPDES MS4 Permit Renewal 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
MS4 Name
Town
Street Address 550 Central Street l
City,State Zip Hudson NC 28638
Phone Number 828-728-8272
E-mail Address [e-mail].
* The owner must be a prinapal executive o14iCer or ranking elected oJiiaal for the aty/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 I Jack Cline
Contact Title I Stormwater Administrator
Employer Western Piedmont Council of Governments
Street Address 1880 2"d Ave NW
NC 28601
I Phone Number 1828485-4222 1
E-mail Address
— ine pnmary contact is the respVonsrare parry woo will oversa+e we aay-ro-aay permrr comp►rance ana
Stunnwater Management Program implementationnth the exception ofenforcement actions, permit
communIcubw7s 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
John Wear
E-mail Address
[e-mail]
Contact Name
Teresa Kinne
E-mail Address
Teresa. [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 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.
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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.
❑ 1 am a ranking elected official for the permitted MS4.
21' 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:
P�tre4a'
Title:
-T—i)wn rn �•
Pecemb"
Signed this q day of 20,E .
* Please note that an orioinal signature is regquired on this form, any required supplemental information, and any
representative authorization. Phohxoples cannot be acrrepted.
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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