2025-04-28_REVISION - M2023002 (16)

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COG500000 Permit Application www.coloradowaterpermits.com 1. Has the applicant reviewed the surrounding area for possible groundwater contamination, such as plumes from leaking underground storage tanks (LUSTs), hazardous waste sites, or additional sources? Applicants are expected to exercise due diligence in evaluating their sites prior to applying for a discharge permit. o Yes o No a NA (no water leaves the pit, or stormwater-only discharge) 2. Is an open LUST located within 0.5 mile of the site? ❑Yes a No *if yes, BTEX analytical data for the mine pit water or discharge must be included with the permit application. The division may request analytical data for additional parameters. Failure to include this data may delay permit application processing until such data is submitted to the division. 3. Is a Superfund site or National Priorities List (NPL) site located within 1 mile of the site? ❑Yes a No *1f yes, analytical data for the mine pit water or discharge,for those parameters associated with the Superfund or NPL facility, must be included with the permit application. Failure to include this data may delay permit application processing until such data is submitted to the division. 4. Is a UMTRA facility located within 1 mite of the site? a Yes a No if yes, analytical data for the mine pit water or discharge, for those parameters associated with the UMTRA facility, must be included with the permit application. Failure to include this data may delay permit application processing until such data is submitted to the division. 5. Is any other (non-LUST, non-Superfund, non-NPL site) known source of contamination, such as a Voluntary Cleanup (VCUP), Environmental Covenant, open RCRA Corrective Action site, or brownfields site located within 0.5 mile of the site? ❑Yes a No *If yes, analytical data for the mine pit water or discharge,for those parameters associated with the known source of contamination,must be included with the permit application. Failure to include this data may delay permit application processing until such data is submitted to the division. 6. Is the sand and gravel facility within the footprint of an historic landfill? o Yes a No If Yes for any of questions 1 -6 above, show location of the source(s) of possible groundwater contamination on the maps required in Item E of this application. In the box below, describe the location, extent of contamination, and possible effect on the discharges from this facility. 7. Is concrete truck washout conducted at the facility? ❑Yes a No If Yes, please provide the following additional information with respect to this discharge: • Location of concrete washout water discharge. Check all that apply. ❑ to surface water ❑ to a lined impoundment or excavation o to the ground o washout water not discharged-water is reused, or o to an unlined impoundment or excavation evaporates • What is the proximity of the discharge to a lake, pond, stream/river, intermittent or ephemeral creek, drainage, irrigation ditch, wetland, etc? WA • Is the discharge within the DRMS permit boundary? wA • What is discharge volume and frequency? N/A 8. Does the facility discharge stormwater runoff from a concrete batch plant? (SIC code 3273) nYes OIo 9. Does the facility discharge stormwater runoff from an asphalt batch plant? (SIC code 2951) EYes CNo 10. Does the facility discharge stormwater runoff from recycled concrete? CYes WIN 11. Does the facility discharge stormwater runoff from recycled asphalt? Des No Page 5 of 8- Revision 2/2021