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'°W, COLORADO <br /> - <br /> e( ! Department of Public <br /> Health&Environment <br /> Dedicated to protecting and improving the health and environment of the people of Colorado <br /> FOR INTERNAL USE ONLY <br /> COG500000 Annual Report Form Reviewer: <br /> Sand and Gravel Mining and Processing Further Review: Yes No <br /> Applicable to Stormwater-only discharges <br /> Part A: Permit Identification Part B: Reporting Period Jan 1 through Dec 31 <br /> General Permit Number: COG500000 (Check one. Report due by February 28 of the following year.) <br /> Facility Certification Number COG50 2017 018 2019 2020 <br /> Part C: Permittee Information <br /> Organization: <br /> Mailing Address: <br /> City: State: Zip: <br /> Part D: Facility Information <br /> Facility Name: <br /> Facility Address: <br /> City: <br /> Facility Contact Name: <br /> Title: <br /> Telephone No: <br /> Email Address: <br /> Part E: Permittee-conducted Inspections <br /> Check the box for which inspection frequency applies to the permitted facility, Part I.J.: <br /> Active Site-4 inspections annually ❑ Inactive Site w/No Exposure-2 ❑ Inactive Site w/Exposure-6 ❑ <br /> (Quarterly) inspections annually(Spring/Fall) inspections annually(Every 2 months) <br /> Provide the date(s) the inspections were conducted, as required by Part I.J of the permit: <br /> If an inspection(s)was not conducted in accordance with the required frequency, attach an explanation of why. <br /> 4300 Cherry Creek Drive S., Denver, CO 80246-1530 P 303-692-2000 www.cotorado.gov/cdphe ' <br /> John W. Hukenlooper, Governor I Larry Wolk,MD,MSPH, Executive Director and Chief Medical Officer �� <br />