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Application for transfer of ownership for all permit certifications and authorizations PART 1 pg 2 <br />1. NEW PERMITTEE INFORMATION (fill out all appropriate contacts) <br />Responsible Position (title) VICE PRESIDENT <br />Held by (person) MATTHEW SPRAGUE <br />Telephone # 970-481-3779 email address SPRAGUESTONE@GMAIL.COM <br />Organization SPRAGUE STONE LLC <br />(Should be same as <br />Formal name on page 1) <br />Mailing address 116 SPRAGUE AVENUE <br />City BERTHOUD State CO Zip 80513 <br />2. DMR COGNIZANT OFFICIAL (i.e. authorized agent) the person authorized to sign and certify the <br />Reports as required by the permit, including Discharge Monitoring Reports (DMR's), Annual Reports, Compli- <br />ance Schedule submittals, and other information requested by the Division. The Division will transmit pre- <br />printed reports (i.e. DMR's) to this person. If more than one person, please add additional pages. <br />This party may not sign application forms. <br />Responsible Position (title) VICE PRESIDENT <br />Held by (person) MATTHEW SPRAGUE <br />Telephone # 970481-3779 email address SPRAGUESTONE@GMAIL.COM <br />Organization SPRAGUE STONE LLC <br />Mailing address 116 SPRAC�'I )F AVFNI )F <br />3 <br />City BERTHOUD State CO Zip 80513 <br />SITE CONTACT local contact for questions relating to the facility and discharge authorized by this <br />permit for the facility <br />Responsible Position (title) VICE PRESIDENT <br />Held by (person) MATTHEW SPRAGUE <br />Telephone # 970481-3779 email address SPRAGUESTONE@GMAIL.COM <br />Organization SPRAGUE STONE LLC <br />Mailing address 116 SPRAGUE AVENUE <br />City BERTHOUD State CO Zip 80513 <br />4. CERTIFIED OPERATOR IN RESPONSIBLE CHARGE (ORC) may designate one or both if needed <br />A. Wastewater Treatment Facility ORC <br />Operator ID Number NIA <br />Operator's Legal Name <br />Organization <br />B. Wasterwater Collection System ORC <br />Operator ID Number N/A <br />Operator's Legal Name <br />Organization <br />