HomeMy Public PortalAboutDept of Natural Resources-Separate Storm Sewer System Permit Reapp FormSTATE OF GEORGIA DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL PROTECTION DIVISION
Phase I Medium Municipal Separate Storm Sewer System (MS41
NPDES Permit Reapplication Form
Part I. General Information
A. Name of Permittee: City of Tybee Island
B. Mailing Address: 403 Butler Avenue
Tybee Island, Georgia 31328
C. Name of responsible official: Jason Buelterman
Title: Mayor
Mailing Address: 403 Butler Avenue
City: Tybee Island State: GA Zip Code: 31328
Telephone Number: (912) 472-5081
D. Designated stormwater management program contact:
Name: Diane Schleicher
Title: City Manager
Mailing Address: 403 Butler Avenue
City: Tvbee Island State: GA Zip Code: 31328
Telephone Number: (912) 472-5070
Email Address: dschleichernn cityoftybee.org
E. Existing NPDES Phase 1 MS4 Permit Number: GAS000212
Part II. Storm Water Management Program (SWMP) Changes
A. Are you proposing any significant changes to your SWMP, other than those
addressed in Part II? Yes _ No X If no, skip to Part III.
B. Please describe any proposed changes to your municipality's SWMP (Note: Upon
evaluation, EPD may notify the MS4 to submit revised pages for inclusion in the
SWMP document):
Part III. Certification Statement
I certify under penalty of law that this document and all attachments were prepared with
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 fine and imprisonment for knowing
violations.
Signature: C 2
Printed Name: /°K
Title: tjA •b ft Date:
(Version 10/16)