State Environmental Review Process (SERP) Mailing List Form

State Environmental Review Process (SERP) Mailing List Form Clean Water State Revolving Fund Program Minnesota Rules 7077.0272, subp. 2.a.A. Minnesota Rules 7077.0277, subp. 3.B. Doc Type: Wastewater Point Source Instructions: This is the complete mailing list that the Minnesota Pollution Control Agency (MPCA) will use to public notice the Environmental Summary or other environmental review documents. Please type names and addresses on this form and return to the MPCA staff engineer. This list should be considered minimum. If a more substantial mailing list is available for the Public Participation Program, it should be added to this mailing list. Please return this mailing list in MS Word format only. Example address blocks: The Honorable Mark Anderson Marv Johnson, City Administrator Minnesota State Senator City of Willmar 135 State Office Building 236 Oriole Avenue St. Paul, MN 55113 Willmar, MN 55699

Municipality name: Project number: Contact name: Phone number: (person completing the form)

Public notice address information 1. The Honorable State Senator: 6. City Administrator/Clerk:

2. The Honorable State Representative: 7. Engineering Consultant:

3. The Honorable County Board Chair: 8. County Planning and Zoning Office:

4. The Honorable Mayor: 9. Watershed District (if established):

5. Township Board Clerk:* 10. Regional Development Commission:

*Include if any portion of the project (including the facility, interceptor, influent or outfall lines) will be located in the township(s). www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwtp2-16 • 2/8/16 Page 1 of 4 To add rows, place your cursor in the last row of the second column and hit tab. Interested groups: (i.e., homeowners associations, Interested citizens: environmental, business, civic, etc., organizations)

To add rows, place your cursor in the last row of the second column and hit tab. www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwtp2-16 • 2/8/16 Page 2 of 4 Property owners: Property owner list should include all property owners of the site to be, or which has been previously acquired. For pond systems, include the property owner(s) of the pond site, spray irrigation site(s) and all property owners of homes within one-fourth mile of the pond site and any clusters of homes within one-half mile of the pond site.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwtp2-16 • 2/8/16 Page 3 of 4 Federal agencies: State agencies: ATTN: Field Supervisor ATTN: Environmental Review Supervisor U.S. Fish and Wildlife Service MN Department of Natural Resources Twin Cities Field Office Division of Ecological and Water Resources 4101 American Boulevard East 500 Lafayette Road, Box 25 Bloomington, MN 55425-1665 St. Paul, MN 55155 -4025

ATTN: Environmental Compliance Chief ATTN: Manager of Government Programs and Compliance U.S. Army Corps of Engineers MN Historical Society St. Paul District Minnesota Historic Preservation Office 180 Fifth Street East, Suite 700 345 West Kellogg Boulevard St. Paul, MN 55101-1678 St. Paul, MN 55102-1906

ATTN: Regional Environmental Officer ATTN: Cultural Resource Director Federal Emergency Management Agency MN Indian Affairs Council Region V Office 161 St. Anthony Avenue, Suite 919 536 South Clark Street, 6th Floor St. Paul, MN 55103 Chicago, IL 60605

MPCA regional office(s):

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats wq-wwtp2-16 • 2/8/16 Page 4 of 4