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STATEOF COLO V 0 For agency use Only <br /> COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit NumberAsslgned <br /> E:ecticatecl tu, a­ J .pr;Mrig the a and unt of the peo,�� ai f� ` COR03• <br /> _ r _ <br /> Water Qual ty Control Division Date Received <br /> 4300 Cherry Creek Drive South " • <br /> WQCD-WQPS-B2 ■`,' `is <br /> Denver,CO 80246-1530 <br /> (3031 692-3S00 www.cola radowaterperm,ts <br /> COLORADO DISCHARGE PERMIT SYSTEM (CDPS) <br /> STORMWATER DISCHARGE ASSOCIATED WITH CONSTRUCTION ACTIVITIES APPLICATION <br /> PHOTO COPIES,FAXED COPIES,PDF COPIES OR EMAILS WILL NOT BE ACCEPTED. <br /> Please print or type.Original signatures are required, <br /> All items must be completed a:curately and In their entirety for the application to be deemed complete. Incomplete applications will not be processed until al <br /> information is received which wA ultimately delay the issuance of a permit.If more space is required to answer any question,please attach additional sheets to the <br /> application form Applications must be submitted by mail or hand delivered to <br /> Colorado Department of Public Health and Environment <br /> Water Quality Control Division <br /> 4300 Cherry Creek Drive South <br /> WQCD-WQPS-62 <br /> Denver,CO 80246.1530 <br /> Arty additional information that you would like the Division to consider in developing the permit should be provided with the application. Examples include effluent data <br /> ardlor modeling and planned pollutant removal strategies. <br /> HOW TO COMPLETE THIS APPLICATION <br /> 1.Online via web browser.You must use Internet Explorer{version 8 and above) All other browsers disable the electronic submission features. <br /> OR <br /> 2.Download and save this form to your computer.Then open Adobe Reader(or Acrobat),select File,then Open and navigate to where the form is saved.This Is the best <br /> option If using a Mac computer(Do not use the Mac Preview program) <br /> PERMIT INFORMATION <br /> Reason for Application: a NEW CERT ❑ RENEW CERT EXISTING CERT# <br /> Applicant Is: ❑ Property Owner 1-4 Contractor/Operator <br /> A.CONTACT INFORMATION—NOT ALL CONTACTS MAY APPLY'indicates required <br /> 'PERMITTEE(if more than one please add additional pages) <br /> •ORGANIZATION FORMAL NAME: SEMA Construction, Inc. <br /> 1)'PERMITTEE CONTACT the person authorized to sign and certify the permit application <br /> This person receives all permit correspondences and is the person responsible for ensuring compliance with the permit <br /> Responsible Person(Title) Environmental Compliance Manager <br /> Currently Held By(Person) FirstName m _ LastName Mang <br /> Cameron _.____- .__.Mm..__ <br /> Telephone 303-627-2600 Email Address cmang@semaconstruction.com <br /> Organization: SEMA Construction, Inc. <br /> Mailing Address: 7353 S Eagle St <br /> —_--------------____ <br /> Centennial CO 80112 <br /> City: _ State __...__.___ 2:p Code _...______-__ <br /> This form must be signed by the Permittee(listed in item 1)to be considered complete. <br /> Per Regulation 61 In all cases,it shall be signed as follows: <br /> In the case of corporations,by a responsible corporate officer.For the purposes of this section,the responsible corporate officer is <br /> responsible for the overall operation of the facility from which the discharge described in the application originates. <br /> In the case of a partnership,by a general partner. <br /> In the case of a sole proprietorship,by the proprietor. <br /> In the case of a municipal,state,or other public facility,by either a principal executive officer or ranking elected official <br /> SW Construction Applladon for SEMA Construcnon,Inc 0 711 312 01 8 r+rc t A s <br />