STORMWATER POLLUTION PREVENTION PROGRAM
WATER RESOURCES LIBRARY
_PLANS AND POLICIES
STORMWATER POLLUTION PREVENTION PROGRAM
4/24/2017 2:29:24 PM
4/24/2017 2:22:51 PM
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www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />wq-strm4-49a • 5/31/13 Page 1 of 20 <br /> <br />MS4 SWPPP Application <br /> for Reauthorization <br />for the NPDES/SDS General Small Municipal Separate <br />Storm Sewer System (MS4) Permit MNR040000 <br /> reissued with an effective date of August 1, 2013 <br />Stormwater Pollution Prevention Program (SWPPP) Document <br />Doc Type: Permit Application <br />Instructions: This application is for authorization to discharge stormwater associated with Municipal Separate Storm Sewer Systems <br />(MS4s) under the National Pollutant Discharge Elimination System/State Disposal System (NPDES/SDS) Permit Program. No fee is <br />required with the submittal of this application. Please refer to “Example” for detailed instructions found on the Minnesota Pollution <br />Control Agency (MPCA) MS4 website at http://www.pca.state.mn.us/ms4. <br />Submittal: This MS4 SWPPP Application for Reauthorization form must be submitted electronically via e-mail to the MPCA at <br />firstname.lastname@example.org from the person that is duly authorized to certify this form. All questions with an asterisk (*) are <br />required fields. All applications will be returned if required fields are not completed. <br />Questions: Contact Claudia Hochstein at 651-757-2881 or email@example.com, Dan Miller at 651-757-2246 or <br />firstname.lastname@example.org, or call toll-free at 800-657-3864. <br />General Contact Information (*Required fields) <br />MS4 Owner (with ownership or operational responsibility, or control of the MS4) <br />*MS4 permittee name: City of Edina *County: Hennepin <br /> (city, county, municipality, government agency or other entity) <br />*Mailing address: 4801 W. 50th Street <br />*City: City of Edina *State: MN *Zip code: 55424 <br />*Phone (including area code): 952-927-8861 *E-mail: email@example.com <br />MS4 General contact (with Stormwater Pollution Prevention Program [SWPPP] implementation responsibility) <br />*Last name: Adler *First name: Laura <br /> (department head, MS4 coordinator, consultant, etc.) <br />*Title: Water Resources Coordinator <br />*Mailing address: 7450 Metro Blvd. <br />*City: City of Edina *State: MN *Zip code: 55439 <br />*Phone (including area code): 952-826-0445 *E-mail: firstname.lastname@example.org <br />Preparer information (complete if SWPPP application is prepared by a party other than MS4 General contact) <br />Last name: Carlson First name: Jesse <br /> (department head, MS4 coordinator, consultant, etc.) <br />Title: Water Resources Project Manager <br />Mailing address: 477 Temperance Street <br />City: St. Paul State: MN Zip code: 55101 <br />Phone (including area code): 651-286-8464 E-mail: email@example.com <br />Verification <br />1. I seek to continue discharging stormwater associated with a small MS4 after the effective date of this Permit, and shall <br />submit this MS4 SWPPP Application for Reauthorization form, in accordance with the schedule in Appendix A, Table 1, with <br />the SWPPP document completed in accordance with the Permit (Part II.D.). Yes <br />2. I have read and understand the NPDES/SDS MS4 General Permit and certify that we intend to comply with all requirements <br />of the Permit. Yes
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