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IL - Application Fee <br />Is the required $400 Permit Application Fee (payable to the MPCA) enclosed? ^Yes <br />• •.- <br />The person with overall, MS4 legal responsibility must sign the application. This person shall be duly <br />authorized to sign the application and may be either a principal executive officer or ranking elected official <br />(Minn. R. 7001.0060). <br />I certify under penalty of law that this document and all attachments were prepared under my direction or <br />supervision in accordance with a system designed to assure that qualified personnel properly gathered and <br />evaluated the information submitted. Based on my inquiry of the person or persons, who manage the system, or <br />those persons directly responsible for gathering the information, the information submitted is, to the best of my <br />knowledge and belief, true. accurate, and complete (Minn. R. 7001_ .0070;. <br />Please note: The MPCA is currently developing a reissuance of the MS4 General Permit. After the Permit is <br />reissued, you will receive information from the MPCA regarding the additional information you will need to <br />submit. <br />Further information on reissuance of the MS4 General Permit is available on the MPCA Municipal Stormwater <br />Web site at <br />http://www.pca. state.mn.us/index.php/water/water-types-and-programs/stormwater/municipal-stormwater/ms4- <br />general-permit-reissuance-201 l .html <br />Authorized Signature of the person with overall, MS4 legal responsibility must sign the application <br />(principal executive officer or a ranking elected official). <br />X <br />Authori.>ed Signature Date <br />Last Nanae First Nanae Title <br />Mailing Address <br />MN <br />Ciry State Zip Code <br />Telephone (include area code) E-Mail Address <br />wq-strm4-52 <br />MPCA MS4 General Permit Application 4 of 4 11/}/] 0 <br />