2015-03-23_PERMIT FILE - M2015008 (2)

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.pplication For Discharges Associated Wh`h Sand & Gravel Mining And Processing N. OTHER ENVIRONMENTAL PERMITS Vr www.colo ra dowaterRg[MjqtSL. com Does this facility currently have any environmental permits or is it subject to regulation under either of the followin ? O. Stormwater Management Plan Certification - REQUIRED SIGNATURE STOP! A Stormwater Manaeement Plan must be completed prior to signing the followine certifications! This item applies to all facilities. A Stormwater Management Plan (SWMP) shall be prepared prior to applying for coverage under the general permit, and the following certification signed. See the SWMP requirements in Appendix B. "I certify under penalty of law that a complete Stormwater Management Plan, as described in Appendix B of this application, has been prepared for my activity. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the Stormwater Management Plan is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said SWMP, including the possibility of fine and impfisonment for knowing violations.', Signature of Legally Responsible Pers n or Authorized Agent (original ink signature required) Date Signed Baxter W. Kirkland Operations Manager Name (printed) Title 1. Signature of Permit Legal Contact (see Item A.1 for signatory requirements) - REQUIRED SIGNATURE [Reg 61.4(1)(h)] "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." GL - : � W • /U✓�� -vii �� .--. Signature of Legally Responsible Person original ink signature required) Date igned Baxter W. Kirkland Operations Manager Name (printed) Title Page 7 of 7 revised Jan 2014 g programs. Permit Name Yes No Applied For, Date Permit No. a. Colorado Division of Reclamation, Mining and Safety— Safety— El 03-05-2015 M- 2015 permit anniversary: -008 b. Underground Injection Control ❑ IN C. Clean Water Act (CWA) Section 404 (Army Corps of Engineers) ❑ d. Resource Conservation and Recovery Act (RCRA) e. CDPS Stormwater ® ❑ 02 -27 -2015 CORON475 f. Colorado State Air Pollution Emission ® ❑ 03 -05 -2015 g. Other O. Stormwater Management Plan Certification - REQUIRED SIGNATURE STOP! A Stormwater Manaeement Plan must be completed prior to signing the followine certifications! This item applies to all facilities. A Stormwater Management Plan (SWMP) shall be prepared prior to applying for coverage under the general permit, and the following certification signed. See the SWMP requirements in Appendix B. "I certify under penalty of law that a complete Stormwater Management Plan, as described in Appendix B of this application, has been prepared for my activity. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the Stormwater Management Plan is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said SWMP, including the possibility of fine and impfisonment for knowing violations.', Signature of Legally Responsible Pers n or Authorized Agent (original ink signature required) Date Signed Baxter W. Kirkland Operations Manager Name (printed) Title 1. Signature of Permit Legal Contact (see Item A.1 for signatory requirements) - REQUIRED SIGNATURE [Reg 61.4(1)(h)] "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." GL - : � W • /U✓�� -vii �� .--. Signature of Legally Responsible Person original ink signature required) Date igned Baxter W. Kirkland Operations Manager Name (printed) Title Page 7 of 7 revised Jan 2014