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STATE OF COLORADO <br />Bill Ritter, Jr,, Governor <br />James B. Martin, Executive Director"i <br />l: t:t irjl <br />Dedicated to protecting and improving the health and environment of the people of Colorado <br />r., a <br />4300 Cherry Creek Dr. S. Laboratory Services Division <br />�+ <br />Denver, Colorado 80246-1530 8100 Lowry Blvd. <br />Phone (303) 692-2000 Denver, Colorado 80230.6928rR? <br />TDD Line (303) 691-7700 (303) 692-3090 <br />Colorado rtment <br />Located in Glendale, Colorado <br />I'Les C I-le.1th <br />u€� I'ulylic Health <br />http://www.cdphe.state.co.us <br />and Environment <br />Colorado Water quality Control Division Notice of Termination <br />Construction Stormwater Inactivation Notice <br />www.coloradowaterpermits.com <br />Print or type all information. All items must be filled out completely and correctly, If the form is not complete, it <br />will be returned. All permit terminations dates are effective on the date approved by the Division. <br />MAIL ORIGINAL FORM WITH INK SIGNATURES TO THE FOLLOWING ADDRESS: <br />Colorado Dept of Public Health and Environment <br />Water Quality Control Division <br />4300 Cherry Creek Dr South, WQCD-P-B2 <br />Denver, CO 80246-1530 <br />FAXED OR EMAILED FORMS WILL NOT BE ACCEPTED, <br />■ PART A. IDENTIFICATION OF PERMIT Please write the permit certification number to be terminated <br />Permit Certification Number (four digits, not "0000"): COR03 _ _ _ _ <br />PART B. PERMITTEE INFORMATION <br />Company Name <br />Mailing Address <br />City <br />Legal Contact Name <br />Title <br />+ PART C. IFACILITY PROJECT INFORMATION <br />Facility/Project Name <br />Location (address) <br />City <br />Local Contact Name <br />Title <br />State Zip code <br />Phone number <br />Email <br />County Zip code <br />Phone number <br />Email <br />Page 1 of 2 form last revised July 2009 <br />