2007-01-18 MPCA App for Permit Transfer/Modification
This form is to transfer a permit or modify permit information for a permitted site with an existing SWPPP.
An Application for General Stormwater Permit for Construction Activity must be used to obtain a new permit.
Use a Subdivision Registration when ownership for a permitted site shifts from one party to multiple other parties.
National Pollutant Discharge Elimination System (NPDES)/State Disposal System (SDS)
General Stormwater Permit for Construction Activity (MN R1 00001)
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',' Permit Transfer/Modification
Minnesota Pollution Control Agency
Construction Stormwater Permit Program
520 Lafayette Road North, St. Paul, MN 55155-4194
NO FEE
Refer to the NPDES/SDS General Stormwater Permit for Construction Activity (MN RIOOOOl)
and the original owner's coverage notification letter as you complete this form. Call the MPCA
Customer Assistance Center at 651-297-22 74 or 800-646.6247 (in Minnesota) for assistance.
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Should you fill out this form? This application can only be used to transfer the permit responsibility for the entire site. If you
wish to transfer the responsibility of a portion of the site, you must use the Subdivision Registration application, available
on the MPCA 's Web site, www.pca.state.mn.us/water/stormwater/stormwater-c.html
1. Stormwater Permit Identification Number
See Notice of Stormwater Permit Coverage or coverage
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MN RI 0000 I-COOO
2. Project Name (As listed on the initial permit application)
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3. Owner Name (As listed on the initial permit application)
4. Contractor Name (As listed on the initial permit
application)
5. Reason for Application (check an that apply)
o New Project Name
o New Contractor
IKJ Contractor Name Change
[j,Contractor Address Change
o New Owner
o Owner Name Change
o Owner Address Change
6. Effective Date of Change
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September 2003
7. New or Same Owner ,
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Business or inn Name
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Last Name
Telephone (include area code)
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Zip Code
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Telephone (include area code)
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Last Name (Alternate Contact)
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First Name
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
information, including the possibility of fine and imprisonment for knowing violations.
I also certify under penalty of law that I have read, understood, and accepted all terms and conditions of the NPDES/SDS General
Stormwater Pe 't Construction Activity (MN RlOOOOI) that authorizes Stormwater discharges associated with the construction site
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Date
The App , ation fo Permit Transfer or Modification form must be signed by:
· Corpor . n: a rincipal executive officer of at least the level of vice-president or the duly authorized representative or agent of the executive officer if
the representative or agent is responsible for the overall operation of the facility that is the subject of the permit application.
· Partnership or Sole Proprietorship: a general partner or the proprietor.
· Municipality, State, Federal or Other Public Agency: principal executive officer or ranking elected official.
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Mailing Address
Last Name (Alternate Contact)
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First Name
Telephone (include area code)
I certify under penalty oflaw 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
information, including the possibility of fine and imprisonment for mowing violations.
I also certify under penalty of law that I have read, understood, and accepted all terms and conditions of the NPDES/SDS General
Stormwater Permit for Construction Activity (MN R 1 0000 1) that authorizes Stormwater discharges associated with the construction
site identifie this orm.
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Date
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Authorized SFt~e
The APplicYor Permll Transfer or Modification form must be signed by:
· Corporation: a pnnclpal executive officer of at least the level of vlce~president or the duly authorized representative or agent of the executive officer if
the representative or agent is responsible for the overall operation of the facility that is the subject of the permit application.
· Partnership or Sole Proprietorship: a general partner or the proprietor.
. Municipality, State, Federal or Other Public Agency: principal executive officer or ranking elected official.
wq-shm2-56
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September 2003