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4. Standard Industrial Classification (SIC) Code(s) for this facility <br />a) ! q I 1 b) _l 2 C), <br />(Include up to four, in order of importance.) <br />d) <br />5_ Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the narne of <br />6. <br />7 <br />the ultimate receiving waters.) <br />U it o rt -- <br />e <br />Describe the industrial activities which take place on site. r <br />under either of the following programs? <br />permits, or is it sub}ect to regulation, <br />Nn Yrns Permit # <br />a) Colorado Discharge Permit System (CDPS or NPDES) X _ <br />b) Colorado Mined Land Reclamation Board _ -X M -85- O L) 9 <br />If Yes, include MLRB permit anniversary date It- 23 -Q3 <br />8. STORMWATER MANACE,EN-r PL-! <br />A Stormwater Management Plan (SWW) shall be prepared prior to applicanion for coverage under a general permit, and the <br />following certification signed. See the SWMP requirements in Appendix A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of the <br />application, has been prepared for my facility. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathering the information, the SWMP is, to the best of my knowledge and belied true, <br />accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said SWMP, <br />including the possibility of fine and imprisonment." <br />Signature of Permit <br />Name (printed) <br />9. Signature of Applicant (legally responsible person) <br />Date Signed <br />Y -r- <br />Title <br />"1 certify under penalty of law that I have personally examined and am familiar with the information submitted in this application <br />and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I <br />believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imptisonmcat." <br />Signature of Permit <br />Name (printed) <br />'/93/sg <br />-2- <br />/I S/o <br />Date Signed <br />>C <br />Tide <br />