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A C D P H E COLORADO For Agency Use Only <br /> CO LI <br /> Water Quality Control Division Date Received / / <br /> Department of Public Heafn b Environment Effective Date / / <br /> APPLICATION FOR TRANSFER OF OWNERSHIP FOR ALL PERMITS, CERTIFICATIONS AND <br /> AUTHORIZATIONS <br /> Signed documents may be mailed to <br /> Colorado Department of Public Health and Environment Water Quality Control Division 4300 Cherry Creek Drive South WQCD-P- <br /> B2 Denver, Colorado 80246-1530 <br /> OR EMAIL digitally signed document to cdphe.wqrecordscenter@state.co.us <br /> 000001244PAEsReMaEoTIFmATONeR JoTeOATQrtlMaER , eresdivheersdesasend in 0000) <br /> TO BE COMPLETED BY NEW PERMITTEE: I hereby apply for a transfer of ownership of this Colorado <br /> Discharge Permit, Certification, or Authorization listed above, which was issued to : <br /> (permittee listed in Part 2 on page 4) <br /> Colorado Legacy Land LLC <br /> I have reviewed the terms and conditions of this permit and accept responsibilities, coverage and <br /> liability (including Stormwater Management Plan where applicable). <br /> If all information is correct, form is complete, and transfer approved, I request this transfer to be <br /> effective <br /> on 5/1/2024 . (If this date is in the past, the effective date will be the date processed by the division.) <br /> The following must be completed for the application to be considered complete: <br /> ❑i. Both parties must sign the form (digital signatures are accepted) page 3 and page 4 <br /> R2. ORIGINAL Form mailed to Division 30 Days Prior to the Transfer Effective Date(which may <br /> be the date property exchanges hands.) <br /> 3. ALL existing invoices paid and verified by the Division. <br /> PROJECT or FACILITY INFORMATION <br /> PERMITTEE ORGANIZATION FORMAL NAME taking liability for this permit: <br /> The legally responsible organization (applicant) is either the owner or operator of the facility or project to which <br /> the permit has been issued, or both if designated as co-permittees by the Division. <br /> PROJECT OR FACILITY NAME Schwartzwalder Mine <br /> FACILITY LOCATION/ADDRESS B300 Glencoe Valley Road <br /> CITY 'Golden I COLORADO ZIPCODE 180402 I COUNTY Jefferson <br /> PERMITTEE ORGANIZATION FORMAL NAME taking liability for this permit: <br /> The legally responsible organization (applicant) is either the owner or operator of the facility or project to which <br /> the permit has been issued, or both if designated as co-permittees by the Division <br /> Colorado Division of Reclamation, Mining and Safety <br /> The applicant must be either the owner and/or operator of site.The application must be signed by the applicant to be considered <br /> complete. In all cases,it shall be signed as follows: <br /> a) In the case of corporations,by a principal executive officer of at least the level of vice[lpresident or his or her duly authorized repre- <br /> sentative,if such representative is responsible for the overall operation of the facility from which the discharge described in the appli- <br /> cation originates. <br /> b) In the case of a partnership,by a general partner. <br /> c) In the case of a sole proprietorship,by the proprietor. <br /> d) In the case of a municipal,state,or other public facility,by either a principal executive officer,ranking elected official,or other duly <br /> authorized employee if such representative is responsible for the overall operation of the facility from which the discharge described in <br /> the form originates. <br /> . CDPHE Rev <br /> 4300 Cherry Creek Drive S., Denver,CO 80246-1530 P 303-692-2000 www.colorado.gov/cdphe �� <br /> CO <br /> 11/2014 <br />