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MS. <br />Notice of into. ki a4 tin coverage <br />General Storm Water Pe mit l$pplication (MN R 040000) <br />for Small Municipal Separate Storm Sewer Systems (MS4s) <br />(Noticed as MN R 580000) <br />Minnesota Pollution Control Agency <br />520 Lafayette Road North, St. Paul, MN 55155 -4194 <br />Application deadline: Mardi 10, 2003 Revised March 10, 2004 <br />Minnesota <br />Pollution <br />Control <br />Agency <br />Please read the instructions care Fully lllld use the "tab- icev to move through the fields of this form. L.titer <br />responses using drop down menus, check: boles and text as indicated. Use the 'sale a5 feature in ,:vi3 Wort to <br />save this template as a document. <br />MSC information <br />A. Application Type <br />Application type: Single site or administrative area 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 applicationJor each site or <br />administrative area. An authorised person with overall responsibility or at officially delegated representative must sign each application form. <br />S. MS4 Owner <br />Cit'v of Little Canada <br />Communiry, municipality, agency or other parry having ownership or operational control of the MS4. <br />515 Little Cannada Road <br />iing Address <br />:le Canada <br />MN 55117 <br />City State Zip Code <br />Ramsey Mississippi River Twin Cities 07010206 <br />County <br />41- 0973960 <br />Major Watershed (see enclosed map) <br />8034325 <br />Federal Tax ID Slate Tax ID <br />C. General Contact <br />Schroeder <br />Greg Public Works Director <br />Last Name First Name <br />General contact (official, staff member, consultant or other) for permit compliance issues. <br />515 Little Canada Road <br />Title <br />Mailing Address <br />Little Canada <br />MN 55117 <br />City <br />65 1.766.4049 <br />State Zip Code <br />grey. scluoederC.ci.little- canada.mn. us <br />Telephone (include area code) <br />E -Mail Address <br />MIL Certifcatialnt ciftt're Sttom- NaterFalrut arr t teventiairn Mayan (SWPW, <i <br />A. <br />Have you developed a Storm Water Pollution Prevention Program for your MS4? <br />Municipalities must demonstrate hots their Sturm IVater Pollution Prevention Prograun will be implemented and <br />enrorcer( over due tent of The jire -rear permit. STVPPPs must incorporate appropriate educational components, <br />VIPs a,a measurable goals. <br />Provide a brief description of the plan to complete t11e SWPPP if "No" is marked above. <br />v11'r:,A:eIS1:honn Water Penn, Appi tea nnn <br />- 1 9 - <br />a <br />Yes ❑No <br />07/10/04 <br />