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COLORADO WATER QUALITY CONTROL DIVISION MODIFICATION APPLICATION <br />www.coloradowaterpermits.com <br />• PART D. DESCRIPTION OF MODIFICATION REQUESTED: <br />If adding outfalls to an existing permit, include outfall number, latitude and longitude of the outfall, flow, receiving waters, and <br />any treatment (see application for new permit for guidance). <br />Modification of the permit to add two new chemicals to be used in the water treatment system for water from Ponds 7 and 8 prior <br />to discharge into the Purgatoire River. The following chemicals will be used: <br />NELCO POL-E-Z 83904 to be used as a flocculant. <br />NELCO EN/ACT DVS4C005 to be used as a coagulant. <br />MSDS sheets for these chemicals are included with this application. <br />The water from the temporary pond water treatment plantwill be discharged into the Purgatoire River at the following location: <br />Latitude 37.155823 <br />Longitude 104.961369 <br />All the effluent limitations and site-specific monitoring requiments for ponds 7 and 8 will apply to the water treatment plant <br />discharge. <br />PART E. CERTIFICATION Required Signatures <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this <br />application and all attachments and that, based on my inquiry of those individuals immediately responsible for <br />obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are <br />significant penalties for submitting false information, including the possibility of fine or imprisonment. <br />"I understand that submittal of this application is for coverage under the State of Colorado Discharge Permit System <br />until such time as the application is amended or the certification is transferred, inactivated, or expired." <br />re Lf Legally Responsible Party <br />d,612,s10-07 <br />Date SiAned <br />Name (printed) Ti le <br />*This modification application shall be signed, dated, and certified for accuracy by the permittee. <br />In all cases, it shall be signed as follows: <br />1. In the case of a corporation, by a principal executive officer of at least the level of vice-president, or his or <br />her duly authorized representative, if such representative is responsible for the overall operation of the <br />operation from which the discharge described herein originates; <br />2. In the case of a partnership, by a general partner; <br />3. In the case of a sole proprietorship, by the proprietor; <br />4. In the case of a municipal, state, or other public operation, by either a principal executive officer, ranking <br />elected official, or other duly authorized employee. <br />Page 2 of 2 form last revised December 2011 <br />