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U <br /> <br />•. <br />Notice of intent to obtain coverage <br />General Storm Water Permit Application (MN R 040000) <br />for Small Municipal Separate Storm Sewer Systems (MS4s) ~---~ <br />.+- <br />(Noticed as MN R 580000) Minnesota <br />Minnesota Pollution Control Agency Pollution <br />520 Lafayette Road North, St. Paul, MN 55155-4194 Control <br />Application deadline: March 10, 2003 <br /> Agency <br />Please read the instructions carefully and use the "tab" key to move through the fields of this form. Enter <br />responses using drop down menus, check boxes and text as indicated. Use the "save as" feature in MS Word to <br />save this template as a document. <br />A. Application Type <br />Application type: Single site or administrative azea If multiple sites, number of attached application forms: <br />MS4s with multiple sites such as campuses, dispersed facilities, or state agency regions/districts, must attach a completed application for each site or <br />administrative area. An authorized person with overall responsibility or an o, f}tcially delegated representative must sign each application form. <br />B. MS4 Owner <br />City of Falcon Heights <br />Community, municipality, agency or other party having ownership or operational comrol of the MS4. <br />2077 W. Larpenteur <br />Mailing Address <br />Falcon Heights MN 55113 <br />City State Zip Code <br />Ramsey Capital Region <br />County Major Watershed (see enclosed map) <br />41-6007644 8030098 <br />Federal Tax ID State Tax ID <br />C. General Contact <br />Worthington Heather City Administrator <br />Last Name First Name Title <br />General coact (official, staff member, consultant or other) for permit compliance issues. <br />2077 W. Larpenteur <br />Mailing Address <br />Falcon Heights MN 55113 <br />Crty State Zip Code <br />651-644-5050 hworthington@cifalcon-heights.mn.us <br />Telephone (include area code) 1iMai1 Address <br />A. Have you developed a Storm Water Pollution Prevention Program for your MS4? <br />Municipalities must demonstrate how their SYorm Water Pollution Prevention Program will be implemented and ®YeS ^No <br />enforced over the term of the, five yearpermit SWPPPs must incorporate appropriate educational components, <br />B11~s and measurable goals. <br />wq-strm 4-52w <br />MPCA MS4 Storm Water Permit Application <br />3q <br />