2005-12-07 MPCA NPDES App
'"
Westwood
December 7, 2005
lil$Ole
DEt '.. ~ll'"l$/)
Ii 1:005 Westwood Professional Services
3701 12th Street North
Suite 206
51. Cloud, MN 56303
Minnesota Pollution Control Agency
Attn: NPDES PERMIT
520 Lafayette Road North
St. Paul, MN 55155-4194
M A I N 320-253-9495
fAX 320-253-8737
TOll fREE 1-800-270-9495
EMAIl wps@Westwoodps.com
www.westwoodps.com
Re: The Shoppes at Towne Lakes Two
Albertville, MN
Ref: 20055134.00 PE
Enclosed for review and approval is the following:
1. MPCA NPDES Application for Permit Transfer/Modification
We need to add School. Lake to item number lIon the original permit.
Sincerely,
WESTWOOD PROCSIONAL SERVICES, INC.
~AT
L~'B
T. Gideon, P.E.
cc: Dan Tempel, Granite City Real Estate
C..n ~'. ~
STABLISHED ILl 197
TWIN CITIESIMETRO
ST. CLOUD
BRAINERD
This form is to transfer a permit or modify permit information for a permitted site with an existing SWPPP.
An Application/or General Stonnwater Permit for Construction Activity must be used to obtain a new permit.
Use a Subdivision Regia/ration when ownership for a permitted site shifts from one party to multiple other parties.
-
~~ -'-""
Minnesota
Pollution
Control
Agency
National Pollutant Discharge Elimination System (NPDES)/State Disposal System (8DS)
General Stormwater Permit for Construction Activity (MN R100001)
Application for ,
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 NPDESlSDS General Stormwater Permit for Construction Activity (MN RtOOOOI)
and the original owner's coverage notification letter as you complete this form. Call the MPCA
Customer Assistance Center at 651-297-2274 or 800-646-6247 (in Minnesota) for assistance.
"
Shouldyoufill out thisform? This application can only be used to transfer the permit responsibility for the entire site./fyou
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.uslwater/stormwater/stormwater-c.html
1. Stormwater Permit Identification Number
See Notice of Stormwater Permit Coverage or cOlIeroge
notification Jelier
2. Project Name (As listed on the initial permit application) The Shoppes at Towne Lakes Two
MN Rl 0000 I-COOO
00000
3. Owner Name (As listed on the initial permit appliCation) Albertville Phase 2, LLC clo Granite City Real Estate
4. Contractor Name (As listed on the initial permit application) Albertville Phase 2, LLC clo Granite City Real Estate
5. Reason for Application (check all that apply)
D New Project Name
D New Contractor
o Contractor Name Change
D Contractor Address Change
o New Owner
o Owner Name Change
o Owner Address Change
Need to add Body of Water:
11. Receiving Waters
School Lake, Lake, Not a Special Water.
6. Effective Date of Change
12 I 2 I 2005
wq-strm2-56
Inn
September 2003
[i~3~~~fiji~:~Ji[f~I~~:~~1~~~~t~ii~~:t~Er~~~5~~(~~i~~~~~l~~~~~J!~l;~~t~~~i~~€!~Y~~[~~~
7. New or Same Owner
Albertville Phase 2, LLC c/o Granite City Real Estate
Business or Finn Name
Keller AI
Last Name First Name
58 10th Avenue South
Mailing Address
Federal Tax ID
President
litle
E-mail
Waite Park
City
MN
State
State Tax ID
( 320) 253 - 0003 ext.
Telephone (include area code)
56387
Zip Code
() ext.
Telephone (include area code)
Last Name (Alternate Contact)
First Name
E-moil
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 fme 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
Storm water Permit Construction Activity (MN R I 0000 1 ) that authorizes Stormwater discharges associated with the construction site
identified on this form.
X i~'<-~~;j~_
Authorized Signature
Date
/~ - z- 05-
The Appllcationjor Permit Tran.'ifer or Mod!/1calionlorm must be signed by:
· Corporation: a principal executive officer 01 at least the 111Ve1 of vice-president or the duly entthorized repre.rentative or agent of the executive officer if
the representative or agent is resp01l$Ible for die overoll operation of the facility that is tire subject of the permit application.
. Partnership or Sole Proprietorship: a general partner or the proprietor.
· Municipality, Slate, Federal or Other Public Agency: principal executive officer or ranking elected official.
8. New or Same Contractor
Albertville Phase 2, LLC clo Granite City Real Estate
Business or Firm Name
Keller AI
Last Name First Name
58 10th A venue South
Mailing Address
Federal Tax ID
President
Title
B-maH
Waite Park
City
MN
State
State Tax ID
( 320) 253 - 0003 ext.
Telephone (include area code)
56387
Zip Code
() ext.
Telephone (include area code)
Last Name (Alternate Contact)
First Name
E-mail
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 infonnation 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 tenns and conditions of the NPDES/SDS General
Stormwater Permit for Construction Activity (MN R100001) that authorizes Stonnwater discharges associated with the construction
site identified on this form. ;;::-'
~-
X //~.--::::"" ~ __..m
~./:- -~
~.
Authorized Signature
/c:.> - o{.l'C:)"~
Dale
TIre Application for Permit Tramifer or Modificationform must be signed by:
. Corporal/fm: a principal executive officer of at least the lewd Q/vice-presiden/ or lhe duly authorized representative or agent qftlre execl/live officer if
the representative or agent is respol1.!iblefor tire overall operalion ofthefadlity thai 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-slrm2-56
2of2
September 2003