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Minnesota Pollution MS4 SWPPP Application <br />Control Agency <br />520 Lafayette Road North for Reauthorization <br />5t. Paul, MN 55155-4194 <br />for the NPDES/SDS General Small Municipal Separate <br />Storm Sewer System (MS4) Permit MNR040000 <br />reissued with an effective date of August 1, 2013 <br />Stormwater Pollution Prevention Program (SWPPP) Document <br />Doc Type: Permit Application <br />Instructions: This application is for authorization to discharge stormwater associated with Municipal Separate Storm Sewer Systems <br />(MS4s) under the National Pollutant Discharge Elimination System/State Disposal System (NPDES/SDS) Permit Program. No fee is <br />required with the submittal of this application. Please refer to "Example" for detailed instructions found on the Minnesota Pollution <br />Control Agency (MPCA) MS4 website at http://www.pca.state.mn.us/ms4. <br />Submittal: This MS4 SWPPP Application for Reauthorization form must be submitted electronically via e-mail to the MPCA at <br />ms4permitprogram.pca(a%state.mn.us from the person that is duly authorized to certify this form. All questions with an asterisk (*) are <br />required fields. All applications will be returned if required fields are not completed. <br />Questions: Contact Claudia Hochstein at 651-757-2881 or claudia.hochstein(a)state.mn.us, Dan Miller at 651-757-2246 or <br />daniel.miller(a)state.mn.us, or call toll -free at 800-657-3864. <br />General Contact Information (*Required fields) <br />MS4 Owner (with ownership or operational responsibility, or control of the MS4) <br />*MS4 permittee name: City of Hugo <br />(city, county, municipality, government agency or other entity) <br />*Mailing address: 14669 Fitzgerald Ave N <br />*City: H <br />*Phone (including area code): 651 7626316 <br />*State: MN <br />*County: Washington County <br />*Zip code: 55038 <br />*E-mail: sduff@ci.hugo.mn.us <br />MS4 General Contact (with Stormwater Pollution Prevention Program [SWPPP] implementation responsibility) <br />*Last name: Anderson *First name: Scott <br />(department head, MS4 coordinator, consultant, etc.) <br />*Title: Director of Public Works <br />*Mailing address: 14669 Fitzgerald Ave N <br />*City: Hugo *State: MN *Zip code: 55038 <br />*Phone (including area code): 651 7626326 *E-mail: sanderson@ci.hugo.mn.us <br />Preparer information (complete if SWPPP application is prepared by a party other than MS4 General contact) <br />Last name: Duff First name: Steven <br />(department head, MS4 coordinator, consultant, etc.) <br />Title: Senior Enaineerinq Technician <br />Mailing address: 14669 Fitzgerald Ave N <br />City: Hugo <br />Phone (including area code): 651 7626316 <br />Verification <br />State: MN <br />Zip code: 55038 <br />E-mail: sduff@ci.hugo.mn.us <br />1. I seek to continue discharging stormwater associated with a small MS4 after the effective date of this Permit, and shall <br />submit this MS4 SWPPP Application for Reauthorization form, in accordance with the schedule in Appendix A, Table 1, with <br />the SWPPP document completed in accordance with the Permit (Part II.D.). ®Yes <br />2. 1 have read and understand the NPDES/SDS MS4 General Permit and certify that we intend to comply with all requirements <br />of the Permit. ® Yes <br />www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />wq-strm4-49a • 5131113 Page 1 of 14 <br />