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COLORADO <br />Department of Public <br />Health b Environment <br />Dedicated to protecting and improving the health and environment of the people of Colorado <br />For Agency Use Only <br />Date Received I / <br />Effective Date <br />Paid Complete <br />APPLICATION FOR TRANSFER OF OWNERSHIP FOR ALL PERMITS, CERTIFICATIONS AND AUTHORIZATIONS <br />PHOTO COPIES, FAXED COPIES, PDF COPIES OR EMAILS WILL NOT BE ACCEPTED. <br />Not providing the signed Original document may result in delay of transfer of the permit, <br />PERMIT, CERTIFICATION, OR AUTHORIZATION NUMBER COR34 -1296 (This number does not end in 0000) <br />(A separate form must be prepared for each Permit, Certification, or Authorization covered by these changes.) <br />TO BE COMPLETED BY NEW PERMITTEE: <br />I hereby apply for a transfer of ownership of this Colorado Discharge Permit, Certification, or Authorization <br />listed above, which was issued to <br />( permittee listed in Part 2 on page 4) CARTER LAKE ENTERPRISES, INC <br />I have reviewed the terms and conditions of this permit and accept responsibilities, coverage and liability <br />(including Stormwater Management Plan where applicable). <br />If all information is correct, form is complete, and transfer approved, I request this transfer to be effective <br />on 10 -1 -2012 , (if this date is in the past, the effective date will be the date processed by the division.) <br />The following requirements have been met: <br />❑ 1. BOTH parties have completed and signed this form - Parts 1 and 2 <br />2. ORIGINAL Form mailed to Division 30 Days Prior to the Transfer Effective Date <br />(which may be the date property exchanges hands.) <br />❑ 3. ALL existing invoices paid and verified by the Division. <br />Payment MUST be received prior to transfer issuance <br />PROJECT or FACILITY INFORMATION <br />PROJECT OR FACILITY NAME SPRAGUE STONE QUARRY <br />FACILITY LOCATION /ADDRESS 17853-8479 N. LARIMER COUNTY RD. 27 <br />CITY I LOVELAND I COLORADO ZIPCODE 180538 1 COUNTY I LARIMER <br />PERMITTEE ORGANIZATION FORMAL NAME taking liability for this permit: <br />The legally responsible organization (applicant) is either the owner or operator of the facility or project to which <br />the permit has been issued, or both if designated as co- permittees by the Division. <br />SPRAGUE STONE LLC <br />The applicant must be either the owner and /or operator of site. The application must be signed by the applicant to be considered com- <br />plate. In all cacoc, it shall he signed ac follows: <br />a) In the case of corporations, by a principal executive officer of at least the level of vice - president or his or her duly authorized represen- <br />tative, if such representative is responsible for the overall operation of the facility from which the discharge described in the application <br />originates. <br />b) In the case of a partnership, by a general partner. <br />c) In the case of a sole proprietorship, by the proprietor. <br />d) In the case of a municipal, state, or other public facility, by either a principal executive officer, ranking elected official, or other duly <br />authorized employee if such representative is responsible for the overall operation of the facility from which the discharge described in <br />4300 Cherry Creek Drive 5., Denver, CO 80246 -1530 P 303 - 692 -2000 www.cotorado.gov /cdphe ®� Rev <br />�J 11.2014 <br />