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Application for transfer of ownership for all permit, certifications and authorizations PART 1 pg 3 <br />5. BILLING CONTACT if different than permittee <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 />Mailing address 116 SPRAGUE AVENUE <br />City BERTHOUD <br />State CO <br />6. OTHER CONTACT TYPES (check below) Add pages if necessary. <br />Responsible Position (title) PROJECT MANAGER <br />Zip 80513 <br />Held by (person) JASON MILES, P.E. <br />Telephone # 970-622-2095 email address JMILES@COFFEY-ENGINEERING.COM <br />Organization COFFEY ENGINEERING & SURVEYING <br />Mailing address 4045 ST. CLOUD DRIVE, SUITE 180 <br />City LOVELAND State CO <br />Zip 80538 <br />Pretreatment Coordinator Compliance Contact <br />Environmental Contact Stormwater MS4 Responsible Party <br />Biosotids Responsible Party Stormwater Authorized Representative <br />Inspection Facility Contact Property Owner <br />WIConsultant Other <br />REQUIRED CERTIFICATION SIGNATURE [Reg 61.4(1)(h)) <br />Signature of Applicant: The applicant must be either the owner and/or operator of site. The application <br />must be signed by the applicant to be considered complete. In all cases, it shall be signed as fol- <br />lows: <br />a) In the case of corporations, by a principal executive officer of at least the level of vice-president or his <br />or her duly authorized representative, if such representative is responsible for the overall operation of <br />the facility from which the discharge described in the 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, ranking <br />elected official, or other duly authorized employee if such representative is responsible for the overall <br />operation of the facility from which the discharge described in the form originates. <br />certify under penalty of law that I have personally examined and am familiar with the information submit- <br />ted herein, and based on my inquiry of those individuals immediately responsible for obtaining the informa- <br />tion, I believe that the information is true, accurate, and complete. I am aware that there are significant <br />penalties for submitting false information, including the possibility of fine and imprisonment. <br />i <br />Signature(Legally Responsibl Party) MATTHEW SPRAGUE Date a �� <br />VICE PRESIDENT <br />Name (printed) --� - Title <br />