2007-5-30 Application for Permit Transfer/Modifcation; MN Pollution Control Agency This form is to transfer a permit or modify permit information for a permitted site with an existiug SWPPP.
� An Application for General Slormwater Permit jor Construction Activiry must be�used fo obtain a new permit.
Use a Suhdivision Registration when owmership far a permitted site shifts from one party to multiple other parties.
� National Pollutant Discharge Elimination Syste.m(NPDES)/State Disposal System(SDS)
�„„1 General Stormwater Permit for Construction Activity (MN R100001)
v-
fViinnesota
Pollution � � � • • •
Control
Agenc�r � ' . ' � ! , •
Minnesota Pollution Control Agency
Construction Stormwater Permit Program NO FEE
520 Lafayette Road North, St. Paul, MN 55155-4194
Refer to the NPDES/SDS General Stormwater Permit for Construction Activit,y(MN R100001)
and the original owner's coverage notification letter as you complete this form.Call the MPCA
Customer Assistance C,enter at 651_-29?-?2?4 n7 gnn_Fd�.��;+� ;;„ ��:r,�����µ�;�;assistanc�.
� Should you fill out this form? This application can only be used to transfer the permit responsibiliry for the entire site. If you
wish to transfer the responsibility of a portion of the site,��ou must use the Subdivision Registration application, avczilable
on the MPCA's Web site, tivww.pca.state.mn.us/water/stormwater/stormwater-c.html
� Construction Acti��ty:)nforma#ion s �9� � �r�:. � T
1. Stormwater Permit Identification Number MN R 1����1-C��� � "� �„ �, �
See Notice of Slormwater Permit Covernge or coverage v�
notificntion lelter
2. Project Name (As listed on the initial permit application) ;�h(1 `-� �(��;�%(�{ ��i.jrN - ��,����
3. Owner Name (As listed on the initial permit application) �}�(��;�� f� ,�, G '"
4. Contractor Name(As listed on the initial permit _ ��j'��'�p,5 �.�?��r�'� ��(�,^�.��a �!�(�
application) _
Permit''T'ransfier or Modificafiio�n Inforr�a#ion.� '"�� � ; '
5. Re�s�.^. fflr�pp.i�atia: (ehe�k all that apFly) �
❑ New Project Name
❑ New Contractor ❑ New Owner
r] Contractor Name Change ❑ Owner Name Change
[�,:Contractor Address C'hange ❑ Owner Address Change
6. Effective Date of Change j � �G> � ���-��
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September 2003
( �esponslbie �arties, ; , ,
7. New or Same Ow-ner
C����t r� ��1-�t-�-fi/,I IE '-I ( - I �� 5 ���,�� � '? (� (�'7(��-
Business or irm Name Federal Tax ID State Tax ID
''r'� .++:.t 1s�i^�e� /if�i�►t G%.c�a.,4�vil�e.r��I wf (7�)�/9'7-33�ext.
Last'�ame First Na e Tide E-mail
�^� ;�1��� � r �,, , Telephone(include area code)
r �� I�'1��u,f;'l-�U'r 1�K {f�}��� ��� �O
Maii ng Addres City State Zip Code �
�;�e � 'f'r� �-3�.:w+o,�-� <;. �'i�,�/C.nw�.kl �/� )y�T-33bYI ext
Last Name(Altemate Contact) First Name E-mai] Telephone(indude areo rode)
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry
of the person or persons who manage this system, or the persons directly responsible for gathering the information, the information is,
to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false
infomiation, including the possibility of fine and imprisonment for lrnowing violations.
1 also certify under penaity of law that I have read,understood, and accepted all terms and conditions of the NPDES/SDS General
Stormwater Pe t Construction Acrivity(MN R100001) that authorizes Stormwater discharges associated with the consriuction site
identified on t is f�rm.
X ., - L-i`�.--�... � �j� �^
Au[horized Si atur Date v
The App ation jo Permil Trnnsfer or Madifcnlion form must be signed by:
• Corpor ' i::a rincipnl execulrve officer of ar leas!the level of vice-president or the duly authorized representative or agent of[he ezecutive off:cer if
the representative or agent is responsible for the overall operntion of the faciliry Ihat is the subject oflhe permi[application.
• Par[nership or Sale Proprietorship:c�genertt!pariner or the proprietor.
• dlunicipalig�,State,Federal or 01her Public Agency:principal executive officer or ranking elected official.
8. New or Same Contractor �
��,��� n� ���� �✓�i��. � � � I �5 ����f a `7 c� � �1 c�
Business or Fir�Nam� � Federal Tax 1D � State Tax ID
r�se �afnt, �rrtMl�{ or ��r.�-le ��. ���.wwt.�'�I �7C3)'�97 :�� ext.
Last Name First me Title E-ma�l Telephone(include area code)
�� � / /�
!� 1 /' �1 /
MailingAddress �r)� � � �1��� ��l� ��j'�� 1
C��Y Sta[e Zip Code
, /, �.,,..,.,.-�- ��'+ �os�,�.t.�•�e.�"cQ G'r' ,� q��ii�t,,.vt.Ks 06� k�97 338�I ext
Last Name(Altemate Contact) F�rst Name E-mail Telephone(include aren code)
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry
of the person or persons who manage this system, or the persons directly responsible for gathering the infom�ation, the informarion is,
to the best of my Irnowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment for lalowing violations.
I I also certify under penalty of law that I have read,understood, and accepted all terms and conditions of the NPDES/SDS General
Stormwater Pemtit for Construction Activity(MN R100001)that authorizes Stormwater discharges associated with the consiruction
site identifie this oml.
� Cww ._ --, L�2i�, O - O
�`— � �
Authorized S nat e Date
The Applic ion a Permit Trnnsfer or Mod�f cntion form must be si ned b :
S Y
• Corpora[iai:n principnl execuiive officer of at leasl lhe level of vice-presiclent or the duly authorized represenlative or agerit of tlae execi�tive officer if
the representntive or agent is responsible for the overall operntion oJthe fncility that is the subject of the permit npplicntian.
• Parinership or Sole Proprietorship:n general partner or!he proprietor.
• dvlunicipa[ity,Sta1e,Federal or Other Public Agency:principal executive officer or ranking elected official,
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