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Application For Discharges Associated With Sand & Gravel Mining And Processing www.coloradowaterpennits.com <br />A. CONTACT INFORMATION <br />PERMITTEE (If more than one please add additional pages) <br />ORGANIZATION FORMAL NAME: Kirkland Construction, LLLP <br />1) PERMITTEE the person authorized to sign and certify the permit application. This person receives all <br />permit correspondences and is legally responsible for compliance with the permit. <br />Responsible Position (Title): Operations Manager <br />Currently Held By (Person): Baxter W. Kirkland <br />Telephone No: 719-489-3385 <br />email addresssh9 @kirklandconstruction.us <br />Organization: Kirkland Construction, LLLP <br />Mailing Address: PO Box 580 <br />City: Rye State: CO Zip: 81069 <br />This form must be signed by the Permittee to be considered complete. Per Regulation 61 In all cases, it shall be signed as <br />follows: <br />a) In the case of corporations, by a responsible corporate officer. For the purposes of this section, the responsible <br />corporate officer is responsible for the overall operation of the facility from which the discharge described in the <br />application 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 or ranking elected official <br />2) DMR COGNIZANT OFFICIAL (i.e. authorized agent) the person or position authorized to sign and certify reports required by <br />permits including Discharge Monitoring Reports [DMR's], Annual Reports, Compliance Schedule submittals, and other <br />information requested by the Division. The Division will transmit pre - printed reports (ie. DMR's) to this person. If more than <br />one, please add additional pages. <br />n Same As 1) Permittee <br />Responsible Position (Title) <br />Operations Manager <br />Currently Held By (Person): Baxter W. Kirkland <br />Telephone No: 719-489-3385 <br />email addresssh9 @kirklandconstruction.us <br />Organization: Kirkland Construction, LLLP <br />Mailing Address: PO Box 580 <br />city: Rye State: CO Zip: 81069 <br />Per Regulation 61: All reports required by permits, and other information requested by the Division shall be signed by <br />the permittee or by a duly authorized representative of that person. A person is a duly authorized representative only <br />if: <br />(i) The authorization is made in writing by the permittee <br />(ii) The authorization specifies either an individual or a position having responsibility for the overall operation of the <br />regulated facility or activity such as the position of plant manager, operator of a well or a well field, superintendent, <br />position of equivalent responsibility, or an individual or position having overall responsibility for environmental <br />matters for the company. (A duly authorized representative may thus be either a named individual or any individual <br />occupying a named position) <br />(iii) Written request is submitted to the Division <br />page 2 of 7 revised Jan 2014 <br />