2015-04-30_REPORT - M2013052 - Laserfiche WebLink

Home Browse Search

COR341720 RENEWAL APPLICATION SUPPLEMENT for COG5O0000 and COR340O00 This form and Table 1 identify information that the permittee must verify and provide, respectively, for the Agnus Del lode claim facility (certification numberCOR341720) . The permittee must complete, sign, and submit the form and Table 1 to the Water Quality Control Division (the Division) by July 244, 2014 to ensure the Division can issue a renewal permit certification in a timely manner. All renewing permittees must comply with all permit requirements, terms and i conditions to be eligible for renewal. Due Date: Permittees must submit this form to the Division no later than July 24, 2014. do Department of Public Health and Environment Water Quality Control Division 4300 Cherry Creek Drive South WQCD -P -81 Denver, Colorado 80246 -1530 INSTRUCTIONS: Division records show the permittee and facility information provided below for the Agnus Del lode claim facility. Please review this information and make changes, as applicable, by crossing out any incorrect information and writing in current information. Instructions for information requested in Table 1 follow the table. Note: Permittees must provide facilityand outfali latitude and longitudes in NAD83 format PERMITTEE AND FACILITY Organization: Cowman Jean Responsible Position (Title): Operator " Currently Held By (Person): Jean M Cowman ,I ,,.j., Telephone No: 719- 314 -8945 email address: - )elwccW!"Wi tt,peak r�-�. ,Ae Mailing Address: 1065 S Woodland Ave Ste i Woodland Park, CO 80863 Name of Facility: Agnus Del lode claim Facility Location: Del Mtn Rd and Aspen Ridge Rd - North by trail, uninc Ef Paso County Facility Latitude and Longitude: Latitude: 38.842878 Longitude: - 104.948956 Facility SIC code: t REQUIRED CERTIFICATION SIGNATURE [Reg 61.4(1)(h)] "I certify under penalty of law that this document was 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." Signature of Responsl a position t Date Signed i Name (printed) f Tie Note: This form must be signed by the P # #ermittee to be considered complete. Regulation 61 requires that, in all cases it be signed as follows: a) In the case of corporations, by a responsible corporate officer. For the purposes of this section, the responsible corporate officer is responsible for the overall operation of the facility from which the discharge described in the application originates. b) In the case of a partnership, by a general partner. c) In the case of a sole proprietorship., by the proprietor. d) In the case of a municipal, state, o " ther public facility, by either a principal executive officer or ranking elected official