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www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats wq-strm4-49a • 5/31/13 Page 1 of 18 MS4 SWPPP Application for Reauthorization for the NPDES/SDS General Small Municipal Separate Storm Sewer System (MS4) Permit MNR040000 reissued with an effective date of August 1, 2013 Stormwater Pollution Prevention Program (SWPPP) Document Doc Type: Permit Application Instructions: This application is for authorization to discharge stormwater associated with Municipal Separate Storm Sewer Systems (MS4s) under the National Pollutant Discharge Elimination System/State Disposal System (NPDES/SDS) Permit Program. No fee is required with the submittal of this application. Please refer to “Example” for detailed instructions found on the Minnesota Pollution Control Agency (MPCA) MS4 website at http://www.pca.state.mn.us/ms4. Submittal: This MS4 SWPPP Application for Reauthorization form must be submitted electronically via e-mail to the MPCA at ms4permitprogram.pca@state.mn.us from the person that is duly authorized to certify this form. All questions with an asterisk (*) are required fields. All applications will be returned if required fields are not completed. Questions: Contact Claudia Hochstein at 651-757-2881 or claudia.hochstein@state.mn.us, Dan Miller at 651-757-2246 or daniel.miller@state.mn.us, or call toll-free at 800-657-3864. General Contact Information (*Required fields) MS4 Owner (with ownership or operational responsibility, or control of the MS4) *MS4 permittee name: City of St. Anthony Village *County: Hennepin/Ramsey (city, county, municipality, government agency or other entity) *Mailing address: 3301 Silver Lake Rd. *City: St. Anthony Village *State: MN *Zip code: 55418-1603 *Phone (including area code): 612-782-3301 *E-mail: jay.hartman@ci.saint-anthony.mn.us MS4 General contact (with Stormwater Pollution Prevention Program [SWPPP] implementation responsibility) *Last name: Hartman *First name: Jay (department head, MS4 coordinator, consultant, etc.) *Title: Director of Public Works *Mailing address: 3301 Silver Lake Rd. *City: St. Anthony Village *State: MN *Zip code: 55418 *Phone (including area code): 612-782-3314 *E-mail: jay.hartman@ci.saint-anthony.mn.us Preparer information (complete if SWPPP application is prepared by a party other than MS4 General contact) Last name: Carlson First name: Jesse (department head, MS4 coordinator, consultant, etc.) Title: WSB & Associates Mailing address: 477 Temperance Street City: St. Paul State: MN Zip code: 55101 Phone (including area code): 651-286-8464 E-mail: jcarlson@wsbeng.com Verification 1. I seek to continue discharging stormwater associated with a small MS4 after the effective date of this Permit, and shall submit this MS4 SWPPP Application for Reauthorization form, in accordance with the schedule in Appendix A, Table 1, with the SWPPP document completed in accordance with the Permit (Part II.D.). Yes 2. I have read and understand the NPDES/SDS MS4 General Permit and certify that we intend to comply with all requirements of the Permit. Yes