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4. Standard Industrial Classification (SIC) code(s) for this facility. (Include up to four, in order of importance.) <br />a) 1 ai 11 _ b) Iq 2 c) d) <br />S. Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the name of <br />the ultimate receiving waters.) <br />6. Describe the <br />7. Other <br />activities which take place on she. <br />under either of the following programs? <br />permits, or is it subject to regulation, <br />I�[n Y�c Perrn4r S <br />a) Colorado Discharge Permit System (CDPS or NPDES) — <br />b) Colorado Mined Land Reclamation Board <br />If Yes, inchde MLRBt anniversary vetaary date !k 23 -'n.3 <br />8. STORMWATER MANAGEIIgrn PLS.! <br />A Stormwater Management Plan (S WW) shall be prepared prior to appliesion for overage under a general permit, and the <br />Mowing certification signed. See the SWMP requirements in Appendix A. <br />Of certify ander penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of the <br />appiiation, has bees 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 belief; 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 />( — W <br />Signature <br />mprisonment." <br />(—Signature of Permit <br />Name (printed) <br />9. Signature of Applicant (legally responsible person) <br />Date Signed <br />Title <br />"I 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 at 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 imprisonment" <br />of Permit <br />Name (printed) <br />'/23/3[ <br />-2- <br />Date Signed <br />Tilde <br />