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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)