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ASSIGNED PERMIT NUMBER <br /> COLORADO <br /> Dedicated to protecting and improving the Date Received <br /> Department of Public health and environment of the people of Colorado <br /> Health b Environment <br /> MM DD YYYY HH-.MM-.SS <br /> Revised:3-2016 <br /> STORMWATER DISCHARGE ASSOCIATED WITH CONSTRUCTION ACTIVITIES APPLICATION <br /> COLORADO DISCHARGE PERMIT SYSTEM (CDPS) <br /> PHOTO COPIES, FAXED COPIES, PDF COPIES OR EMAILS WILL NOT BE ACCEPTED. <br /> Any additional information that you would like the Division to consider in developing the permit should be provided with <br /> the application. Examples include effluent data and/or modeling and planned pollutant removal strategies. <br /> Beginning July 1, 2016, invoices will be based on acres disturbed. <br /> DO NOT PAY THE FEES NOW—Invoices will be sent after the receipt of the application. <br /> Disturbed Acreage for this application (see page 4) <br /> ❑ Less than 1 acre ($83 initial fee, $165 annual fee) <br /> ❑ 1-30 acres ($175 initial fee, $350 annual fee) <br /> ❑ Greater than 30 acres ($270 initial fee, $540 annual fee) <br /> A. PERMIT INFORMATION <br /> Reason for Application <br /> El NEW CERT ❑ RENEW CERT <br /> ❑ MODIFICATION ❑ TRANSFER <br /> ❑ CHANGE OF CONTACT ❑ TERMINATION <br /> Existing Cert# <br /> B. PERMITTED PROJECT/FACILITY INFORMATION <br /> Facility Name: Penn Mine Original ID: <br /> Property Address 1: 484 WILLIAM PENN Property Address 2: County: Lake <br /> City: Leadville State: CO Zip Code: 80123 <br /> Latitude: 39.249844 Longitude: -106.2467 <br /> SIC Code Description <br /> 1041 Gold ores <br /> 1044 Silver ores <br /> Receiving Water Name Receiving Water Type <br /> Arkansas River Immediate <br /> Mississippi River Ultimate <br /> C. CONTACT INFORMATION <br /> 1 OF 4 <br />