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GENERAL PERMIT APPLICATION <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH <br />SAND AND GRAVEL PRODUCTION <br />For AaencY Use Onl <br />COR -SO <br />OPERATIONS (AND OTHER Date Received <br />NONMETALLIC MINERALS Year Month Day <br />EXCEPT FUEL) <br />(Permit No. COG -500000) <br />Please print or type _ Do not attempt to complete this form before reading the instructions - <br />1. Is this the correct application for your facility?? This application is only for the discharge of stormwater. <br />Do you discharge any of the following process generated wastewaters from your facility? <br />a (So) a Yes Product wash waters <br />&o Yes Maintenancr/equipment wash waters <br />a (into ; 's' Yes Transport waters (e.g., slurries) <br />0 Yes Scrubber waters (crushers or classifiers) <br />Yes Mine dewatering (groundwater and/or maoff from the mine) . <br />If you answered Yes to any of these questions, do not complete this application. You must instead complete the Process <br />Water and Stormwater Discharges Associated with Sand aad Gravel application for this facility, which is available from <br />the Division. <br />2. Name and address of permit applicant: <br />Company Name; <br />Federal Taxpayer (or Employer) <br />Mailing Address . t <br />City, State and Zip Code: 0 <br />Phone Number. (2'21> Ak:2 - (3-4 1 Who is applying for the permit? a a Operator <br />Local Contact (familiar with facility): P h:l ; F 4- S r rVb"A'? <br />rifle: T*� i t A ev Phone Number. -2A9 ► <br />3. Location of the facility: <br />Street Address: 2S! 13 -8!i:24 a t s:, Stale and Zip Code:.1.r23r�.1 a� � .. A atP <br />County: ,� •d,II r-- -__ Name of facility: <br />Legal Location (Township, Range. section, 1/4 section): <br />Latin & and Longitude: ' s► <br />Type of Facility: • New (beginning operations after 1011192) ($s of 1 <br />7/93ft <br />4- <br />