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Attachment B <br /> Minnesota Pollution, MS4 SWPPP Application <br /> rl, Control Agency <br /> 520 Lafayette Road North for Reauthorization <br /> St.Paul,MN 551..55-4194. <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.pcap_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.hochsteingstate.mn.us, Dan Miller at 651-757-2246 or <br /> daniel.millerostate.mn.us, or call toll-free at 800-657-3864. <br /> General Contact Information ('IReq ulir d ioelUs) <br /> MS4 Owner (with ownership or operational responsibility, or control of the MS4) <br /> *MS4 permittee name: City of Roseville *County: Ramsey <br /> (city, county,municipality,government agency or other entity) <br /> *Mailing address: 2660 Civic Center Drive <br /> *City: Roseville *State: MN *Zip code: 55113 <br /> *Phone(including area code): 651-792-7041 *E-mail: duane.schwartz@ci.roseviIle.mn.us <br /> MS4 General contact(with Stormwater Pollution Prevention Program [SWPPP] implementation responsibility) <br /> *Last name: Giga *First name: Kristine <br /> (department head, MS4 coordinator, consultant, etc.) <br /> *Title: Civil Engineer, MS4 Permit Coordinator <br /> *Mailing address: 2660 Civic Center Drive <br /> *City: Roseville *State: MN *Zip code: 55113 <br /> *Phone(including area code): 651-792-7048 *E-mail: kristine.giga@ci.roseville.mn.us <br /> Preparer information (complete if SWPPP application is prepared by a party other than MS4 General contact) <br /> Last name: Leaf First name: Ron <br /> (department head, MS4 coordinator, consultant, etc.) <br /> Title: SEH Inc. , Principal I Sr. Engineer <br /> Mailing address: 3535 Vadnais Center Drive <br /> City: St. Paul State: MN Zip code: 55110 <br /> Phone (including area code): 651.765.2998 E-mail: rleaf@sehinc.com <br /> Verification <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 ILD.). ® 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 15 <br />