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MS Word Template <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 />(Noticed as MN R 580000) <br />Minnesota Pollution Control Agency <br />520 Lafayette Road North, St. Paul, MN 55155 -4194 <br />Application deadline: March 10, 2003 <br />Minnesota <br />Pollution <br />Control <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 doermient. <br />MS4 Information <br />:. <br />A. Application Type <br />Application type: Single site or administrative area If multiple sites, number of attached application fon is: <br />MS4s with multiple sites such as campuses, dispersed facilities, or state agency regions/districts, must attach a completed application for each site o <br />administrative area. An authorized person with overall responsibility or an officially delegated representative must sign each application form. <br />B. MS4 Owner <br />City of Little Canada <br />Community, municipality, agency or other pasty having ownership or operational control of the MS4. <br />515 Little Cannada Road <br />Mailing Address <br />Little Canada <br />MN 55117 <br />City <br />Ramsey <br />State Zip Code <br />Mississippi River Twin Cities 07010206 <br />County <br />41- 0973960 <br />Major Watershed (see enclosed map) <br />8034325 <br />Federal Tax ID State 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 />651.766.4049 <br />State Zip Code <br />greg.schroeder@ci.little-canada.mn.us <br />Telephone (include area code) <br />E -Mail Address <br />IL. Certification: of the. Storm Water. Pollution Preventian. Program (SWPPP) <br />A. <br />Have you developed a Storm Water Pollution Prevention Program for your MS4? <br />Municipalities must demonstrate /ww their Storm Water Pollution Prevention Program will be implemented and <br />enforced over the term of the Jive -year permit. SfVPPPs must incorporate appropriate educational components, <br />BMPs and measurable goals. <br />Provide a brief description of the plan to complete the SWPPP if "No" is marked above. <br />MPCA MS4 Storm Water Permit nppi ication 1 of 3 <br />Yes ❑No <br />02/06/03 <br />