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STATE OF COLORADO <br />John W. Hickenlooper, Governor <br />Larry Wolk, MD, MSPH <br />Executive Director and Chief Medical Officer <br />Dedicated to protecting and Improving the health and environment of the people of Colorado <br />4300 Cherry Creek Dr. S. <br />Denver, Colorado 80246 -1530 <br />Phone (303) 692 -2000 <br />Located in Glendale, Colorado <br />www.colomdo.gov /cdphe <br />COR900000 Annual Report Form <br />Stormwater Discharges Associated <br />with Non - Extractive Industrial Activity <br />Coto <br />* o <br />1876 <br />Colorado Department <br />of Public Health <br />and Environment <br />Date Received: <br />Date Entered: <br />Date Reviewed: <br />Adequate: Yes No <br />Part A: Permit Identification: <br />Part B: Reporting Period: Jan 1 through Dec 31 <br />General Permit Number: COR900000 <br />(Check one. Report is due by March 31 of the following year.) <br />Facility Certification Number COR90 ® g <br />® 2013 <br />❑ 2014 <br />❑ 2015 <br />112016 <br />Part C: Permittee Information: <br />Organization: <br />Mailing Address: _ 170 Z- 1J • loo te- �d <br />City: L­4 , kO,,, State: U-3 Zip: 10 k a5 <br />Part D: Facility Information: <br />t� <br />Facility Name: �o►�rrl,�t._e v�s�r.�t;. ay Vsw�fi ���1 ^ t-Ao f e ?_Q� <br />Facility Address: <br />City: <br />Facility Contact Name: ►` La. w C e H C C <br />Title: c <br />Telephone No: 2 °i \ - j L4 -- <br />Email Address: �� a �.3 �� vtC.� �� t ta, wY UN r LA-LA, Lc>" -, <br />Part E; Permittee- conducted Inspection Dates: (Provide the date the inspection was conducted for each quarter, as <br />required by Part I.G of the permit). <br />Jan-Mar: � � � 3 Ap, -June: (o �-ti t 73 <br />July -Sept: t 3 Oct -Dec: t -2— 1 7-,u 113 <br />Fore; date- November 2013 <br />