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HomeMy WebLinkAboutNCS000409_Belmont Permit Renewal Application_20210805DNPDES MS4 Permit Application Form FW 0 Vj National Pollutant Discharge Elimination System (NPDES) mam—��' 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 MS4 Name C 4 0 Q� Owner Name* 1Iff Owner Title r Street Address mm e-cn*ba City,State Zip-� M 2. d 2 Phone Number '7 Q — s E-mail Address amlITT RonhA21 * The owner must be a principal executive otter br ranking elected official for tlfe 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 \ . Contact Title DA" r W1 Employer Street Address a� CDAWAXN Ci State Zip_Z Z Phone Number d Ll -90- Zd (0 E-mail Address bQ 4-, d ** The primary contact is the responsible pa who will oversee the d-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(Ofo\ V-1RAM{� Y 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 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 havingverail responsibility for the stormwater permit. Signature:* Print Name: Title: C1 dJ c Signed thisdayof 20�Z * Please note that an ri in signature is required on this form, any required supplemental infonnahon, 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 2 of 2