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Summary a StainrWaterr a utianl P` <br />=i?ragram; (SSINPPPI <br />R.equir d :Ap ;; ... itachnr_nts <br />Complete a one page SWPPP Summary Sheet and a BMP Description Sheet for each type of BMP that will <br />implemented. (See last two pages of the application form.) <br />A. Is the SWPPP Summary Sheet attached? <br />B. is one BMP Description Sheet attached for each BMP? <br />C. How many BMP Description Sheets are attached? <br />Yes No <br />®Yes ❑No <br />imitations: afCoverage� <br />A. Part II Limitations on Coverage and Appendix C <br />f. have read Part II Limitations on Coverage and Appendix C of the MS4 general pei,nit and EYes <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 (11154s) 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, <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 peuuit versus a general perurit. <br />❑Yes ZNo <br />2. Does the MS4 discharge into waters with a Restricted Discharge as defined in Minn. R. ❑Yes ZNo <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 Srnall Municipal <br />Separate Storm Sewer Systems (IvIS4s) for further information. <br />3. Does the MS4 discharge into Trout Waters as defined in Minn. R. 6264.0050 subp. 2 & ❑Yes ZNo <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 (*IS4s) for further information. <br />4. Does the MS4 discharge into Wetlands as defined in Minn. R. 7050.0130, subp. F? See <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 <br />Environmental Review as required by State or federal laws? See Part IX of the <br />Guidance .1an ral for Small Municipal Separate Storm Sewer Systems (MS4s) for further <br />information. <br />ZYes END <br />]Yes ❑No <br />Does the MS4 have a process to evaluate discharges whose direct_ indirect, interrelated, EYes ❑No <br />'nterconnected, or independent impacts may jeopardize a listed Endangered or <br />Threatened Species or adversely modify a designated critical habitat? See Part IX of the <br />Gaaidarrce _Hamra/ for Small _Municipal Separate Storm Sewer Systems (,LIS4.0 for further <br />rotor? nation. <br />,\154 :>«mn ' ier <br />- 2 3 - <br />,Y3/1( <br />