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Industrial Stormwater
Change Form
NPDES/SDS Industrial Stormwater
Multi-Sector General Permit
Doc Type: Permit Application
Instructions: Use this form to notify the Minnesota Pollution Control Agency (MPCA) about changes at your facility that affect your
Industrial Stormwater Permit. Changes you can make with this form are listed under “Change Information.” Changes that
require you to restart your sampling schedule are noted. Print a copy of the completed form for your records, or save the completed
form to your computer in a location where you can easily find it.
Submittal: The person who certifies this form can email the completed form to iswprogram.pca@state.mn.us using “Change
Form” as the subject line. A manual confirmation email will be sent. If you do not receive an email confirmation within two business
days, please contact us.
Questions: Email the program at iswprogram.pca@state.mn.us or call the Stormwater Hotline at: 651-757-2119 or
800-657-3804 (non-metro only).
This form cannot be used to:

Change no exposure exclusion status to general permit coverage

Change general permit coverage to no exposure exclusion

Transfer ownership for a facility that has the no exposure exclusion

Transfer the permit when your business moves to a different physical location
Submit a new permit application to make any of the changes listed above.
Facility Information
(as listed on the original permit application form)
Facility name:
Facility address:
Permit number:
City:
State:
Contact name:
Contact phone:
Zip code:
Change Information
Check all changes that apply and fill out the corresponding section(s) below. Fill in changes only.
1. Change in facility address information.
2. Change in contact information.
3. Change description of industrial activities.
4. Change acreage of industrial activities.
5. Correction to latitude/longitude.
Changes to items 6-10 will reset your sampling calendar to Year 1.
6. Change Standard Industrial Classification (SIC) code.
7. Change narrative activity.
8. Change in discharge to a regulated Municipal Separate Storm Sewer System (MS4).
9. Change where facility stormwater discharges to (surface water discharges).
10. Change monitoring locations.
Change Items
(Complete only the items that have changed.)
1. Change in facility address information. (Such as a reassigned street name or zip code.)
Facility name:
Facility address:
City:
State:
Zip code:
County:
www.pca.state.mn.us •
wq-strm3-60 • 11/12/14
651-296-6300
•
800-657-3864
•
TTY 651-282-5332 or 800-657-3864
•
Available in alternative formats
Page 1 of 4
2. Change in contact information.
A.
Owner
Owner contact name:
Company/Organization name:
Owner mailing address:
City:
State:
County:
Fax:
Phone:
B.
Zip code:
Email:
Operator
Operator contact name:
Company/Organization name:
Operator mailing address:
City:
State:
County:
Phone:
C.
Zip code:
Fax:
Email:
Contact person
Contact name:
Company/Organization name:
Contact mailing address:
City:
State:
County:
Fax:
Phone:
D.
Zip code:
Email:
Fees/billing contact person
Contact name:
Company/Organization name:
Contact mailing address:
City:
State:
County:
Zip code:
Fax:
Phone:
Email:
3. Change description of industrial activities at the facility. Please provide a new description.
4. Change acreage of industrial activities.
Old acreage of industrial activities:
New acreage of industrial activities:
5. Correction to facility latitude/longitude.
(Example: 44. 956497)
New decimal latitude:
(Example:-93. 084619)
New decimal longitude:
How was this information obtained?
Other-please explain:
GPS Unit
Online Map Locator
Topographic Map
6. Change SIC code. Your sampling calendar resets to Year 1 in the next calendar quarter with this change.
Former SIC code:
Primary
Additional
New SIC code:
Primary
Additional
www.pca.state.mn.us •
wq-strm3-60 • 11/12/14
651-296-6300
•
800-657-3864
•
TTY 651-282-5332 or 800-657-3864
•
Available in alternative formats
Page 2 of 4
7. Change narrative activities. Your sampling calendar resets to Year 1 in the next calendar quarter with this change.
Add
Inactivate
A4 Timber products: discharges from wet decking storage areas
Add
Inactivate
C1 Runoff from phosphate fertilizer manufacturing facilities that comes into contact with any raw
materials, finished product, by-products, or waste products
Add
Inactivate
D2 Discharges from production of asphalt emulsions areas
Add
Inactivate
E3 Cement manufacturing facility, material storage runoff
Add
Inactivate
K1 Hazardous waste treatment/storage/disposal facility for discharges not subject to effluent
limitations in 40 CFR pt. 445, subp. A
Add
Inactivate
K2 Hazardous waste treatment/storage/disposal facility for discharges subject to effluent
limitations in 40 CFR pt. 445, subp. A
Add
Inactivate
L1 Municipal solid waste landfill areas closed in accordance with 40 CFR 258.60
Add
Inactivate
L2 Open or closed non-hazardous waste landfill and land application site not discharging to
surface water
Add
Inactivate
L3 Landfill that discharges to surface waters stormwater that has directly contacted solid waste
Add
Inactivate
O1 Coal fired and oil fired steam electric generating facility
Add
Inactivate
O2 Nuclear, natural gas fired, and any other fuel source used for steam electric generation
Add
Inactivate
O3 Runoff from coal storage piles at steam electric generating facility
Add
Inactivate
S3 Existing and new primary airports with 1,000 or more annual jet departures that discharge
wastewater associated with airfield pavement deicing that contains urea commingled with
stormwater
Add
Inactivate
T1 Treatment works with design flow of one million gallons per day or more or are required to
have an approved pretreatment program under 40 CFR pt. 403
8. Change in discharge to a regulated MS4. Your sampling calendar resets to Year 1 with this change.
Do industrial stormwater discharges flow from the facility to a regulated MS4?
Yes
No
Name of former regulated MS4:
Name of new regulated MS4:
9. Change surface water discharges. Your sampling calendar resets to Year 1 in the next calendar quarter with this
change.
Add or delete the surface waters that receive your stormwater discharges. Indicate the name, type, whether each is within one
mile of your facility, if it is an Outstanding Resource Value Water (ORVW), or if it is impaired.





Type: lake, stream, river, pond, wetland, ditch, fen, trout stream, or lake trout lake.
ORVWs: Listed in Appendix A of the Industrial Stormwater Multi-Sector General Permit. For questions, contact the Water
Quality Standards Unit at 651-296-6300 or 800-657-3864.
Trout streams or lake trout lakes; refer to Minnesota Revisor of Statutes webpage at:
http://www.revisor.mn.gov/rules/?id=6264.0050, Minn. Stat. § 6264.0050, subps. 2 and 4
Wetlands; refer to Minnesota Revisor of Statutes webpage at: http://www.revisor.mn.gov/rules/?id=7050.0186, Minn. Stat.
§ 7050.0186, subp. 1a.B
Impaired waters; refer to MPCA webpage at: http://www.pca.state.mn.us/mvri1126. Only check "yes" if the water is
impaired for your required monitoring parameters or pollutant surrogates.
Delete/
Add
Name of surface water
Type of surface water
Ex: Delete
Ex: St. Croix River
Ex: River
Yes
No
Yes
No
Yes
No
Ex: Add
Ex: Unnamed Ditch
Ex: Ditch
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
www.pca.state.mn.us •
wq-strm3-60 • 11/12/14
651-296-6300
•
800-657-3864
•
Within
one mile
Impaired
water
ORVW
TTY 651-282-5332 or 800-657-3864
•
Available in alternative formats
Page 3 of 4
10. Change monitoring locations. Your sampling calendar resets to Year 1 in the next calendar quarter with this change.
Add or delete monitoring locations.
Add
#
Describe the location of the
monitoring location
Latitude
Longitude
List subsector of
narrative activities
and/or SIC codes
for monitoring
location
Ex: Delete
1
Ex: NW corner of facility, near road
Ex: 44. 956497
Ex: -93. 084619
Ex: SIC 3111
Ex: Add
1
Ex. SW corner of facility, near rain garden
Ex: 44. 956499
Ex: -93. 084626
Ex: O2
Delete/
Certification
Federal and state regulations require the authorized signer to be:
A. Corporation: a principal executive officer of at least the level of vice president.
B. Partnership or sole proprietorship: a general partner or the proprietor, respectively.
C. Municipality, state, federal, or other public facility: a principal executive officer or ranking executive official.
D. If the operator of the facility is different than the owner, both the operator and the owner must sign.
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 gathered and evaluated the information submitted. I certify that
based on my inquiry of the person, or persons, who manage the system, or those persons directly responsible for gathering the
information, the information submitted 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 civil and criminal penalties.
By typing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that this information can
be used for the purpose of processing this form.
Owner authorized signature:
Operator authorized signature (if different):
Name:
Name:
(This document has been electronically signed.)
(This document has been electronically signed.)
Title:
Title:
Date (mm/dd/yyyy):
Date (mm/dd/yyyy):
www.pca.state.mn.us •
wq-strm3-60 • 11/12/14
651-296-6300
•
800-657-3864
•
TTY 651-282-5332 or 800-657-3864
•
Available in alternative formats
Page 4 of 4