HomeMy WebLinkAboutIowa Department of Natural Resources-11/4/2013IOWA DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL PROTECTION DIVISION
INFORMATION REQUIRED TO ACCOMPANY APPLICATION FOR THE
MUNICIPAL SEPARATE STORM SEWER SYSTEM (MS4) PERMIT
For coverage under the NPDES General Permit the following fees apply:
Five year Permit Fee - $1250.00 Maximum coverage is five years.
DNR Cashier's Use Only
0253-542-SW08-00-0449
NAME OF THE CITY OR UNIVERSITY FOR WHICH PERMIT COVERAGE IS SOUGHT:
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HOW MANY ACRES OR SQUARE MILES OF LAND ARE COVERED BY THE CITY OR UNIVERSITY AT THE
TIME OF APPLICATION?
kotTh SQc)2-L (v\ILE3
NAMES OF THE RECEIVING WATERS (Into what rivers, creeks, lakes or other waterbodies does your runoff water flow?):
C E\ C -- SZ\ - , 3LA C k c1 cia-Rk
CONTACT ADDRESS: Give name, mailing address and telephone number of a contact person. This will be the address to which
all correspondence regarding your application will be directed.
NAME:
M,1 C_ 1 \A Oq-SeN(
ADDRESS:
X1( MUU e rtfat Sfl CI -11
CITY:
,,)1'2\71:71RLo0
STATE:
‘DP's
ZIP CODE:
Sbia`z)
TELEPHONE
(irS ) a91-yaia
RESPONSIBLE ENTITY ADDRESS: Give name, mailing address and telephone number of the entity responsible for compliance
with the permit. This will be the address to which all correspondence regarding your permit will be directed.
NAME:
i1(CYOR-
ADDRESS:
1 S 11 U Lia L RRY S-rR.EG'(
CITY:
L. c-\VALLc
STATE:
\ L
ZIP CODE:
S61-tS
TELEPHONE
(3\6\) ail- H3b\
(over)
04-2008
542-8039
The following certification must be signed by the principal executive officer or the ranking elected official of the city or university for
which permit coverage is sought. If more than one city or a city and university are applying for coverage with this application together,
the certification must be signed by the individual designated in the 28E agreement. If applicable, a copy of this agreement must be
provided with the application.
CER'TIF'ICATION
I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed
to assure that qualified people properly gathered and evaluated the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, this 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.
NAME (please print)
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TITLE:
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St
SIG
� GGY
DATE:
04-2008 542-8039
CITY OF WATERLOO
Council Communication
City Council Meeting: November 4, 2013
Prepared: October 28, 2013
Dept. Head Signature: Eric Thorson, PE, City Engineer
# of Attachments: 1
SUBJECT: IDNR MS4 Permit Renewal
Submitted by: Phillip Schupnert, Storm Water Specialist
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Recommended City Council Action: Approve resolution and allow Mayor to sign the MS4
application form.
Summary Statement: Every 5 years, the Iowa DNR permit which the city is required to carry for
our storm sewer discharge must be renewed. This form is the required documentation needed for
reapplication and renewal. The permit also carries a renewal fee of $1,250.
Expenditure Required $1,250
Source of Funds Stormwater
Policy Issue N/A
Alternative N/A
Background Information:
IOWA DEPARTMENT OF NATURAL RESOURCES
ENVIRONMENTAL PROTECTION DIVISION
INFORMATION REQUIRED TO ACCOMPANY APPLICATION FOR THE
MUNICIPAL SEPARATE STORM SEWER SYSTEM (MS4) PERMIT
For coverage under the NPDES General Permit the following fees apply:
Five year Permit Fee - $1250.00 Maximum coverage is five years.
DNR Cashier's Use Only
0253-542-S W 08-00-0449
NAME OF THE CITY OR TJNIVERSITY FOR WHICH PERMIT COVERAGE IS SOUGHT:
HOW MANY ACRES OR SQUARE MILES OF LAND ARE COVERED BY THE CITY OR UNIVERSITY AT THE
TIME OF APPLICATION?
(12L1 ko-n' SQop,Q,t; (`'\1LE3
NAMES OF THE RECEIVING WATERS (Into what rivers, creeks, lakes or other waterbodies does your runoff water flow?):
EOM-- cLWJ2-1 3 C k O Aor< ca_ak
CONTACT ADDRESS: Give name, mailing address and telephone number of a contact person. This will be the address to which
all correspondence regarding your application will be directed.
NAME:
CC AC_1uOVSBN
ADDRESS:
-4A c riUL-e1z(4
r
CITY:
,,)pclra_Lo o
STATE:
c R
ZIP CODE:
S-1:3-4 t.-7-,
TELEPHONE
(1q) ),R 1- (.) w
RESPONSIBLE ENTITY ADDRESS: Give name, mailing address and telephone number of the entity responsible for compliance
with the permit. This will be the address to which all correspondence regarding your permit will be directed.
NAME:
(Y\ A=Yut-
ADDRESS:
x-15 0 ULf3E22Y S Ze&'f
CITY:
.JQc� t;\Ll. CO
STATE:
1 Dtzpt-
ZIP CODE:
satibb
TELEPHONE
(3 \G\) al-- ‘-1-5\
(over)
04-2008
542-8039
The following certification must be signed by the principal executive officer or the ranking elected official of the city or university for
which permit coverage is sought. If more than one city or a city and university are applying for coverage with this application together,
the certification must be signed by the individual designated in the 28E agreement. If applicable, a copy of this agreement must be
provided with the application.
CERTIFICATION
I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed
to assure that qualified people properly gathered and evaluated the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, this 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.
NAME (please print)
TITLE:
ERNES' Q. CLI -Itc
r�i‘-‘(DR_
SIGN f :DATE:
�i ��;�om (/19 .„(g -e
i,
04-2008 542-8039