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Minnesota Pollution Control Agency National Pollutant Discharge Elimination System (NPDES)/State Disposal System (SDS) PLEASE SUBMIT TO: Minnesota Pollution Control Agency Construction Stormwater Permit Program 520 Lafayette Road North, St. Paul, MN 55155-4194 AlPCJ usemill- F.X111:, Chem r{ PLEASE READ: This form is for new permit applications only. Use the Transfer/Modification form to transfer a permit to one party or the Subdivision Registration form for multiple parties. All forms are available at the MPCA's Construction Stormwater Web site: www.pca.state.Mn.us/water/stormwater/stormwater-c.litml. Please refer to the application instructions and the NPDES/SDS General Stormwater Permit for Construction Activity (MN R10000 I) as you complete this form. Brackets `[ ]' refer to the Stormwater Permit, which is included with this application. Call the MPGA Customer Assistance Center at 651-297-2274 or 800-646-6247 (in Minnesota) for assistance. 1 Are you ready to apply? -- 1. Stormwater Pollution Prevention Plan (SWPPP) a. Has a Stormwater Pollution Prevention Plan been developed for this project and incorporated ❑Yes [:]No into the project's plans and specifications? [see attached General Stormwater Permit Part IIIA] b. Are erosion prevention measures addressed in the SWPPP'? [Part IV.B] ❑Yes ❑No c. Are sediment control measures addressed in the SWPPP? [Part IV.C] ❑Yes ❑No d. Are dewatering and basin draining addressed in the SWPPP? [Part IV.D] ❑Yes ❑No c. Are inspections and maintenance addressed in the SWPPP? [Part IV.E] ❑Yes [:]No f. Are pollution prevention management measures addressed in the SWPPP? [Part IV.F] ❑Yes [:]No g. Is final stabilization addressed in the SWPPP'? [Part IV.G] ❑Yes ❑No h. If an environmental review was required, did you incorporate all stormwater related mitigation ❑Yes []No [:INA measures contained in the review into the SWPPP? STOP if you responded No to any question above. A SWPPP must be developed prior to submitting a permit application. Complete the above requirements and check Yes before submitting this application. Continue if you responded Yes or NA to all questions above. 2. Discharges to Special Waters a. Are all stormwater discharges that may flow from the project to a Special Water that is located []Yes ❑No [INA within 2,000 feet of any project discharge points addressed in the SWPPP to meet the permit conditions in Appendix A, Part A -C? STOP if you responded No, Complete the above requirements and check Yes before submitting this application. Continue if you responded Yes. 3. Additional Application Review a. Will the project include alternative treatment methods? [Part 11LC.5] if yes, this application and the ❑Yes ❑No alternative treatment plans must be submitted a minimum of 90 days before construction starts. b. if yes, are the plans attached? ❑Yes ❑No c. Will the project disturb 50 acres? AND Is there a discharge point within 2000 feet of an impaired or ❑Yes [:]No special water whose discharge may reach an impaired or special water listed in Appendix A of the permit? [Part 11.B.1.b] If yes, this application and the SWPPP must be submitted a mininuun of 30 days before construction starts. d. if yes, is the SWPPP attached? ❑Yes ❑No 4. Application Fee Is the required S400 Application Fee (payable to the MPGA) enclosed? ❑Yes wq-slrm?-57 I of 3 Revised 4/06