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<br />~ ~~ ~~-- <br />MS VVotd Tern late <br /> <br />Notice of intent to obtain coverage <br />General Storm Water Permit Application (MN R 040000) <br />for Small Municipal Separate Storm Sewer Systems (MS4s) <br />(Noticed as MN R 580000) <br />Minnesota Pollution Control Agency <br />520 Lafayette Road North, 51. Paul, MN 55155-4194 <br />Application deadline: March 10, 2003 <br /> <br /> <br /> <br />lnstructicll1S <br /> <br /> <br />U,l I1H\ ve <br /> <br />the Ilclcb <br />L'se the " :~ave <br /> <br /> <br />In <br /> <br />to <br /> <br />rC:'''fJOr1ses uSlng ch\'l.xn rT1Cnus. <br />~;,a\'c (hi:; as d <br /> <br />~ <br />~ I.~ MS~4 ~tll~LmatiorL ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~~~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ <br /> <br />A. Application Type <br /> <br />Application type: Single site or administrative area If multiple sites, number of attached application forms: <br /> <br />MS4s with multiple sites such as campuses, dispersedfaGilities, or state agency regions/districts, must attach a completed application for each site or <br />administrative area. An authorized person with overall responsibility or an officially delegated representative must sign each applicationfonn. <br /> <br />B. MS4 Owner <br />City of Roseville <br />Community, municipality, agency or other party having ownership or operational control of the MS4, <br />2660 Civic Center Drive <br /> <br />Mailing Address <br />toseville <br /> <br />MN <br /> <br />55113 <br /> <br />City <br />Ramsey <br />County <br />14-6007849 <br /> <br />State <br /> <br />Zip Code <br /> <br />Mississippi- 07010206 <br /> <br />Major Watershed (see enclosed map) <br />9002170 <br /> <br />Federal Tax ID <br /> <br />State Tax ID <br /> <br />C. General Contact <br />Schwartz <br /> <br />Duane <br /> <br />Pub. Works Director <br /> <br />Last Name First Name Title <br />General contact (official, stafTmember, consultant or other) for permit compliance issues. <br /> <br />2660 Civic Center Drive <br /> <br />Mailing Address <br />Roseville <br /> <br />MN <br /> <br />55113 <br /> <br />City <br />651-490-2220 <br /> <br />State Zip Code <br />duane.schwartz@ci.roseville.mn.us <br /> <br />E-Mail Address <br /> <br />Telephone (include area code) <br /> <br /> <br />A. Have you developed a Storm Water Pollution Prevention Program for your MS4? [SJVl1S DNo <br />Municipalities must demonstrate how their Storm Water Pollution Prevention Program will be implemented and <br />enforced over the term of the jive-year permit. SWPPPs must incorporate appropn'ate educational components, <br />BMPs and measurable goals. <br /> <br />Provide a brief description of the plan to complete the SWPPP if"No" is marked above. <br />MPCA MS4 Storm Water Pennit Application I of 8 <br /> <br />02106103 <br />