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Attachment D M MINNESOTA POLLUTION MS4 Part 2 Permit Application CONTROL AGENCY 520 Lafayette Road North Authorization to discharge stormwater associated with St. Paul, MN 55155-4194 small Municipal Separate Storm Sewer System (MS4) Stormwater Pollution Prevention Program (SWPPP) Document Doc Type: Permit Application Instructions: Submitting this application confirms your intent to receive authorization to discharge stormwater under the National Pollutant Discharge Elimination System/State Disposal System (NPDES/SDS) MS4 General Permit (MNR040000). This application is due within 150 days from the issuance date of the MS4 General Permit (MNR040000). Throughout this application there are text fields with a typical maximum limit of four lines. If you need to provide information in a text field that exceeds the maximum limit, please submit an attachment(s) with supplemental information that is labeled with the corresponding field number (e.g., 9.J.). Submittal: This application form and any associated documents (i.e., total maximum daily load (TMDL) application, any supplemental information) must be submitted electronically. To submit this form electronically, open the form using Internet Explorer Web browser or Adobe Acrobat Reader in order for the submit button to work properly. (If you do not have Acrobat Reader, you can download a free version at https:Hget.adobe.com/reader/.) Send the form to the Minnesota Pollution Control Agency (MPCA) by clicking the submit button at the end of the form (a "send email" window should open with the form attached), you can click on "Send" and then close the form. If you do not see a "send email", save the form to your computer and attach the form to an email message, using "MS4 Part 2 Permit Application" as the subject line to ms4permitprogram. pca(�state.mn.us. Review/Public Notice process: The MPCA will review the application for completeness. Incomplete applications will be returned. If the MPCA determines the application is complete, the MPCA will make a preliminary determination to issue permit coverage and place the application on public notice for 30 days. Once the applicant addresses any applicable comments or hearing requests, the MPCA will make a final determination to issue permit coverage to the applicant. Please note, this application is intended to provide information about an applicant's existing SWPPP. An applicant that receives permit coverage is responsible for complying with all new applicable requirements set forth in the MS4 General Permit (MNR040000) by deadlines specified in Appendix B of the reissued permit. Questions: If you have any questions, need additional information, contact MPCA staff. To find the staff assigned to your MS4, refer to the https://stormwater.pca.state.mn.us/index.php?title=MS4 staff contact information and staff assignments; or see the staff contact information on the MPCA's MS4 webpage at https://www.pca.state.mn.us/water/municipal-stormwater-ms4 Note: All questions with an asterisk(") are required fields, and the form will not submit without the fields completed. General contact information 1. MS4 Owner (with ownership or operational responsibility, or control of the MS4) *MS4 permittee name: 1.A. Roseville, City of *Mailing address (City, county, municipality, government agency or other entity) 1.C. 2660 Civic Center Drive *City: 1.D. Roseville *State: 1. E. MN 2. MS4 General contact (with SWPPP implementation responsibility) *County: 1.13. Ramsey *Zip code: 1.F.551113 *Last name: 2.A. Johnson *First name: 2.13. Ryan (Department head, MS4 coordinator, consultant, etc.) *Title: 2.C. Environmental Manager *Mailing address 2.D. 2660 Civic Center Drive *City: 2.E. Roseville *Phone (including area code): 2.1-1. (651) 792-7049 *State: 2.F. MN *Zip code: 2.G. 55113 *Email: 2.1. ryan.johnson@cityofroseville.com 3. Preparer information (complete if SWPPP application is prepared by a party other than MS4 General contact) Last name: Title: 3. C. 3.A. (Department head, MS4 coordinator, consultant, etc.) Mailing address: 3.E. C ity: 3. F. Phone (including area code): 3.1. First name: 3.B. Organization: 3.D. State: 3.G. Zip code: 3.H. Email: 3.J. https://www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats wq-strm4-49a • 9123120 Page 1 of 32