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Required Application Attachments <br />Complete a one page SWPPP Summary Sheet and a BMP Description Sheet for each type of BMP that will <br />be implemented. (See last two pages of the application form) <br />A. Is the SWPPP Summary Sheet attached? ®Yes ^No <br />B. Is one BMP Description Sheet attached for each BMP? ®Yes ^No <br />C. How many BMP Description Sheets are attached? 21 <br />A. Part II Limitations on Coverage and Appendix C <br />I have read Part II Limitations on Coverage and Appendix C of the MS4 general permit and ®Yes <br />certify that we intend to comply with the applicable requirements of those sections. <br />B. Special Waters <br />Please refer to the Guidance Manual for Small Municipal Separate Storm Sewer Systems (MS4s) and the <br />enclosed map to complete this section.. <br />1. Does the MS4 discharge into Prohibited Waters as defined in Minn. R. 7050.0180, DYes ®No <br />subp. 3, 4, and 5? See Attachment Four of the Guidance Manual for Small Municipal <br />Separate Storm Sewer Systems (MS4s) for further information. If yes, please list below <br />and contact Lou Flynn at (651) 296-6575 or louis.flynn@state.mn.us. Be advised that <br />you will be required to obtain an individual permit versus a general permit. <br />• 2. ~ Does the MS4 dischaz a into water <br />g s vv~th a Restricted Discharge as defined in Minn. R DYes ®No <br />7050.0180, subp. 6, 6a, and 6b? If yes, please list below and comply with Part IX, <br />Appendix C, Item B. See Attachment Four of the Guidance Manual for Small Municipal <br />Separate Storm Sewer Systems (MS4s) for further information. <br />3. Does the MS4 discharge into Trout Waters as defined in Minn. R. 6264.0050 subp. 2 & ^Yes ®No <br />4? If yes, please list below and comply with Part IX, Appendix C, Item C. See <br />Attachments Two and Three of the Guidance Manual for Small Municipal Separate <br />Storm Sewer Systems (MS4s) for further information. <br />4. Does the MS4 discharge into Wetlands as defined in Minn. R 7050.0130, subp. F? See ^Yes ®No <br />Attachment Four of the Guidance Manual for Small Municipal Separate Storm Sewer <br />Systems (MS4s) for further information. <br />5. Does the MS4 have a process to evaluate discharges that require applicable DYes ^No <br />Environmental Review as required by State or federal laws? See Part IX of the <br />Guidance Manual for Small Municipal Separate Storm Sewer Systems (MS4s) for further <br />information. <br />6. Does the MS4 have a process to evaluate discharges whose direct, indirect, interrelated, ®Yes ^No <br />interconnected, or independent impacts may jeopazdize a listed Endangered or <br />Threatened Species or adversely modify a designated critical habitat? See Part IX of the <br />Guidance Manual for Small Municipal Separate Storm Sewer Systems (MS4s) for further <br />MPCA MS4 Storm Water Permit Application <br />33 <br />