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HomeMy WebLinkAboutNCS000422_Black Mountain Permit Renewal Application_20210414NPDES 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 Permit No. NCS 000422 MS4 Name Town of Black Mountain Owner Name* Josh Harrold Owner Title Town Manager Street Address 160 Midland Ave City, State, Zip Black Mountain, NC 28711 Phone Number 828-419-9300 E-mail Address Josh.harrold@townofbiackmountain.or * 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 Jessica Trotman Contact Title Planning Director Employer Town of Black Mountain Street Address 160 Midland Ave City,State Zip Black Mountain NC 28711 Phone Number 828-419-9300 E-mail Address Jessica.trotman@townofblackmountain.or ** 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 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. ❑ Imam a ranking elected official for the permitted MS4. 2e"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:* V-'v Print Name: A. �Vvj j Title: Signed this ay of 20, ...(7. * 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 Page 2of2