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COG500000 Permit Application www.coloradowaterpermits.com <br />Page 2 of 8 - Revision 2/2021 <br />B.CONTACT INFORMATION <br />1.Permittee Information <br />Organization Formal Name: ___________________________________________________________ <br />Permittee Name: the person authorized to sign and certify the permit application. This person receives all <br />permit correspondences and is responsible for ensuring compliance with the permit. <br />Responsible Position (Title): ______________________________________________ <br />Currently Held By (Person): ______________________________________________ <br />Telephone No: _________________________________ <br />Email address: ___________________________________ <br />Mailing Address: _______________________________________________________ <br />City: ________________________ State: ______________ Zip: _____________ <br />This form must be signed by the permittee to be considered complete. Per Regulation 61, in all cases, it shall <br />be signed as follows: <br />a)In the case of corporations, by a responsible corporate officer. For the purposes of this section, the <br />responsible corporate officer is responsible for the overall operation of the facility from which the <br />discharge described in the application 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 or ranking <br />elected official. <br />2.DMR Cognizant Official (i.e. authorized agent) the person or position authorized to sign and certify reports <br />required by permits including Discharge Monitoring Reports [DMR’s], Annual Reports, Compliance Schedule <br />submittals, and other information requested by the division. The division will transmit pre-printed DMR’s to <br />this person. If more than one, please add additional pages. <br />□Same as 1) Permittee <br />Responsible Position (Title): ______________________________________________ <br />Currently Held By (Person): ______________________________________________ <br />Telephone No: _________________________________ <br />Email address: ___________________________________ <br />Organization: __________________________________________________________ <br />Mailing Address: _______________________________________________________ <br />City: ________________________ State: ______________ Zip: _____________ <br />Per Regulation 61: All reports required by permits, and other information requested by the Division shall be <br />signed by the permittee or by a duly authorized representative of that person. A person is a duly authorized <br />representative only if: <br />a)The authorization is made in writing by the permittee <br />b)The authorization specifies either an individual or a position having responsibility for the overall <br />operation of the regulated facility or activity such as the position of plant manager, operator of a well <br />or a well field, superintendent, position of equivalent responsibility, or an individual or position having <br />overall responsibility for environmental matters for the company. (A duly authorized representative may <br />thus be either a named individual or any individual occupying a named position) <br />c)Submitted in writing to the Division <br />Raptor Materials LLC <br />VP of Operations <br />Robert Haun <br />720-698-2455 <br />rhaun@raptormaterialsllc.com <br />8120 Gage Street <br />Frederick CO 80516 <br />Environmental Manager <br />Ben Wilson <br />832-335-0230 <br />bwilson@raptormaterialsllc.com <br />Raptor Materials LLC <br />8120 Gage Street <br />Frederick CO 80516