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Application for <br />Municipal Separate Storm Sewer Systems (MS4) <br />l4'lii-~r~~s~~a General Permit <br />~U~llltlt~"Il <br /> <br />~~~~' RETURN THIS APPL/CATON TO: <br /> Minnesota Pollution Control Agency <br /> Municipal Division <br /> 520 Lafayette Road North <br /> St. Paul, MN 55155-4194 <br />A. Application Type <br />Application for re-issuance of coverage (this MS4 applied in 2006) <br />New applicant (this MS4 has no previous application for MS4 coverage on file at MPCA) <br />B. MS4 Owner (city, county, community, municipality, government agency or other party/entity) with <br />ownership or operational responsibility, or control of the MS4. <br />o~- E I k 12tic1 <br />(City, county, municipality, government agency or other party/entity) <br />13065 Dro~~ `~cfl~a~/ <br />Mailing Address <br />~i k ~., ~~ MN 5 533D <br />Ci State Zip Code <br />~~~~~~ <br />coamty <br />Federal Tax ID State Tax lD <br />C. General Contact (director, department head, MS4 coordinator, consultant or other person with SWPPP <br />implementation responsibility) for all general correspondence about Permit compliance issues between the <br />MPCA and your MS4. <br />~10.ttiq KP b~CLc~ ~ vf~~~e.~, <br />Last <br />First Nan:e <br />h <br />Title <br />:h~ <br />i3b6S bco~.a ~~~a~ <br />Mailing Address <br />~Ik ~.~~ MN SS33c~ <br />,Wiry State Zip Code <br />Telephone (include area code) <br /> <br />E-Mail <br />wq-stnn4-52 <br />MPCA MS4 General Permit Application 3 of 4 11/1/10 <br />