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<br /> <br /> <br />Complete a one page SWPPP Summary Sheet and a BMP Description Sheet for <br />"e implemented. (See last two pages of the application form.) <br /> <br />type of BMP that will <br /> <br />A. Is the SWPPP Summary Sheet attached? <br />B. Is one BMP Description Sheet attached for each BMP? <br />C. How many BMP Description Sheets are attached? <br /> <br />Dyes IZJNo <br />DYes IZJNo <br /> <br />:l~",,, 'l".tlDjm.DJ~~~f ~o~~~ ~ e ~ mn ~~~~~ n ~ ~ ~ ~~ .~ .~~ _ ~~~.~ . . . <br /> <br />A. Part II Limitations on Coverage and Appendix C <br />I have read Part II Limitations on Coverage and Appendix C of the MS4 general permit and <br />certifY that we intend to comply with the applicable requirements of those sections. <br /> <br />IZJYes <br /> <br />B. Special Waters <br />Please refer to the Guidance Manual/or Small Municipal Separate Storm Sewer Systems (MS4s) and the <br />enclosed map to complete this section. <br /> <br />I. Does the MS4 discharge into Prohibited Waters as defined in Minn. R. 7050.0180, DYes IZJNo <br />subp. 3,4, and 5'1 See Attachment Four of the Guidance Manual/or Small Municipal <br />Separate Storm Sewer Systems (MS4s) for further information. If yes, please list below <br />and contact Lou Flynn at (651) 296-6575 or louis.flynn@state.mn.us. Be advised that <br />you will be required to obtain an individual permit versus a general permit. <br /> <br />2. Does the MS4 discharge into waters with a Restricted Discharge as defined in Minn. R. DYes IZJNo <br />7050.0180, subp. 6, 6a, and 6b? If yes, please list below and comply with Part IX, <br />Appendix C, Item B. See Attachment Four of the Guidance Manual/or Small Municipal <br />Separate Storm Sewer Systems (MS4s) for further information. <br /> <br />3. Does the MS4 discharge into Trout Waters as defined in Minn. R. 6264.0050 subp. 2 & DYes IZJNo <br />4'1 If yes, please list below and comply with Part IX, Appendix C, Item C. See <br />Attachments Two and Three of the Guidance Manual/or Small Municipal Separate <br />Storm Sewer Systems (MS4s) for further information. <br /> <br />4. Does the MS4 discharge into Wetlands as defined in Minn. R. 7050.0130, subp. F? See IZJYes DNo <br />Attachment Four of the Guidance Manual/or Small Municipal Separate Storm Sewer <br />Systems (MS4s) for further information. <br /> <br />5. Does the MS4 have a process to evaluate discharges that require applicable IZJYes DNo <br />Environmental Review as required by State or federal laws? See Part IX ofthe <br />Guidance Manual/or Small Municipal Separate Storm Sewer Systems (MS4s) for further <br />information. <br /> <br />6. Does the MS4 have a process to evaluate discharges whose direct, indirect, interrelated, IZJYes DNo <br />interconnected, or independent impacts may jeopardize a listed Endangered or <br />Threatened Species or adversely modifY a designated critical habitat? See Part IX of the <br />Guidance Manual/or Small Municipal Separate Storm Sewer Systems (MS4s) for further <br /> <br />MPCA MS4 Storm Water Permit Application <br /> <br />50f8 <br /> <br />02/06/03 <br />