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Attachment B <br />(.�V MinnesotaPollutionPollution <br />Control Agency MS4 SWPPP Application <br />520 Lafayette Road North for Reauthorization <br />St. Paul, MN 55155-4194 <br />for the NPDES/SDS General Small Municipal Separate <br />Storm Sewer System (MS4) Permit MNRO4OOOO <br />reissued with an effective date of August 1, 2013 <br />Stormwater Pollution Prevention Program (SWPPP) Document <br />DocType: PemetAppiication <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 MID:/MvwHvOca.statemn.us/ms4. <br />Submittal: This MS4 SWPPPApplication for Reauthorization form must be submitted electronically via e-mail to the MPCA at <br />ms4permitprogram.pcao) tate.mn.us from the person that is duly authorized to certify this form. Al questions with an asterisk (*) are <br />required fields. Al applications will be returned if required fields are not completed. <br />Questions: Contact Claudia Hochstein at 651-757-2881 or claudia.hochstein(o)state.mn.us. Dan Miller at 651-757-2246 or <br />daniel.miller(o)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 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(o)ci.roseville.mn.us <br />MS4 General contact (with Stormwater Pollution Prevention Program [SWPPP] implementation responsibility) <br />*Last name: Giga *First name: Kristine <br />(department head,, M54 coordinator, conauiten( 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(o)ci.roseville.mn.us <br />Preparer information (complete if SWPPP application is prepared by a party other than MS4 General contact) <br />Last name: <br />(department head,, M54 coordinator, conauiten( etc) <br />First name: <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@sehinacom <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 SWPPPApplication 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 11. D.). Z 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. Z Yes <br />www.pca.state.mn.us 651-N6-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in altematry formats <br />v q-strm4-49a • 5131113 Page 1 of 15 <br />