2024-04-22_GENERAL DOCUMENTS - M1977300 (2)

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CDPHE COLORADO For Agency Use Only 1 Water Quality Control Division Date Received / / CO Department of Public Heaith&Environment Effective Date APPLICATION FOR TRANSFER OF OWNERSHIP FOR ALL PERMITS, CERTIFICATIONS AND AUTHORIZATIONS Signed documents may be mailed to Colorado Department of Public Health and Environment Water Quality Control Division 4300 Cherry Creek Drive South WQCD-P- B2 Denver, Colorado 80246-1530 OR EMAIL digitally signed document to cdphe.wqrecordscenter@state.co.us PERMIT CERTIFICAION OR AUTHORIATION.NUMBER C00001244 (This umber do s not a din 0000) (A separateform must be prepared or eac Permit, ertl ication, or Authorlcadon covered by t ese c anges.) TO BE COMPLETED BY NEW PERMITTEE: I hereby apply for a transfer of ownership of this Colorado Discharge Permit, Certification, or Authorization listed above, which was issued to : (permittee listed in Part 2 on page 4) Colorado Legacy Land LLC • I have reviewed the terms and conditions of this permit and accept responsibilities, coverage and liability (including Stormwater Management Plan where applicable). If all information is correct, form is complete, and transfer approved, I request this transfer to be effective on 5/1/2024 . (If this date is in the past, the effective date will be the date processed by the division.) The following must be completed for the application to be considered complete: 1. Both parties must sign the form (digital signatures are accepted) page 3 and page 4 2. ORIGINAL Form mailed to Division 30 Days Prior to the Transfer Effective Date(which may nbe the date property exchanges hands.) 3. ALL existing invoices paid and verified by the Division. PROJECT or FACILITY INFORMATION PERMITTEE ORGANIZATION FORMAL NAME taking liability for this permit: The legally responsible organization (applicant) is either the owner or operator of the facility or project to which the permit has been issued, or both if designated as co-permittees by the Division. PROJECT OR FACILITY NAME Schwartzwalder Mine FACILITY LOCATION/ADDRESS B300 Glencoe Valley Road CITY Golden COLORADO ZIPCODE 80402 COUNTY Jefferson PERMITTEE ORGANIZATION FORMAL NAME taking liability for this permit: The legally responsible organization (applicant) is either the owner or operator of the facility or project to which the permit has been issued, or both if designated as co-permittees by the Division Colorado Division of Reclamation, Mining and Safety The applicant must be either the owner and/or operator of site.The application must be signed by the applicant to be considered complete. In all cases, it shall be signed as follows: a) In the case of corporations, by a principal executive officer of at least the level of vice president or his or her duly authorized repre- sentative,if such representative is responsible for the overall operation of the facility from which the discharge described in the appli- cation originates. b) In the case of a partnership,by a general partner. c) In the case of a sole proprietorship,by the proprietor. d) In the case of a municipal,state,or other public facility,by either a principal executive officer, ranking elected official,or other duly authorized employee if such representative is responsible for the overall operation of the facility from which the discharge described in the form originates. CDPHE 4300 Cherry Creek Drive S., Denver, CO 80246-1530 P 303-692-2000 www.colorado.gov/cdphe COQ 81/2014