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4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />a) % q ) % b) Iq 2 c) d) <br />5. Receiving Stream: The name of the receiving strearn(s). (If discharge is to a ditch or storm sewer, also include the name of <br />6 <br />the ultimate receiving waters.) <br />U 11 t v R �) �t c. h r,, c 1 � r`4 � he, h�� ln,✓a.s t � arc' rl�r• <br />aA. t- r j <br />Describe the industrial activities which take place on site. <br />7. Other <br />under either of the following programs? <br />a) Colorado Discharge Permit System (CDPS or NPDES) <br />b) Colorado Mined Land Reclamation Board <br />If Yes, include MLRB permit anniversary date -'r->3 <br />S. STORIIMWATER MANAGES MNT FLtiN <br />permits, or is it subject to regulation, <br />I <br />� � r <br />A Stormwater Management Plan (SWMP) shall be prepared prior to application for coverage under a general permit, and the <br />following certification signed. See the SWMP requirements in Appendix A- <br />"I certify under penalty of law that a complete Storrnwater Management Plan, in compliance with Appendix A of the <br />application, has been prepared for my facility. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathering the information, the SWMP is, to the best of my knowledge and belief, true, <br />accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said SWMP, <br />including the possibility of fine and imprisonment." <br />�JG r , ��� <br />Signature of Permit <br />Name (printed) <br />9_ Signature of Applicant (legally responsible person) <br />Date Signed <br />s� <br />Title <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application <br />and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I <br />believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonment" <br />Signature of Permit AppAant 000 Date Signed <br />( , is h ; �d row• t� Sc S/%r ear . <br />Name (printed) Title <br />1/93/sg -2- <br />