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COG500000 Permit Application www.coloradowaterpermits.com <br /> 2. Are any of the receiving waters identified in the Table G.1 above a storm sewer system, ditch, or manmade <br /> conveyance? <br /> ❑Yes No <br /> Note: if discharge is to a storm sewer system, ditch, or manmade conveyance, approval from the owner of the <br /> system must be obtained before discharge. <br /> 3. Did the applicant obtain approval from the owner of the storm sewer system, ditch, or manmade conveyance? <br /> ❑Yes o No a NA-discharge is not to a storm sewer system, ditch, or manmade conveyance. <br /> H. CHEMICAL ADDITION/TREATMENT <br /> If chemical additives, settling agents, flocculants, or other materials are proposed for use in or to treat <br /> wastewater/stormwater prior to discharge, please submit a Chemical Approval Form with this application. <br /> 1. Is chemical addition/treatment proposed for this facility? <br /> ❑ Yes a No <br /> 2. Did applicant submit a Chemical Approval Form with this application? <br /> o Yes a No -chemical addition/treatment not proposed <br /> I. OTHER ENVIRONMENTAL PERMITS <br /> Does this facility currently hold any environmental permits, or is it subject to regulation, under any of the <br /> following programs? <br /> Permit Name Yes No Effective Date Permit No. <br /> 1. Colorado Division of Reclamation, Mining and Safety ✓ I I <br /> 2. Underground Injection Control j uu <br /> 3. Clean Water Act (CWA) Section 404- US COE n <br /> 4. Resource Conservation and Recovery Act (RCRA) 1 I <br /> 5. CDPS Stormwater -� <br /> 6. Colorado State Air Pollution Emission <br /> 7. Other —" ❑ <br /> J. ACTIVITY DURATION <br /> When did the activity commence? NOT YET <br /> What is the estimated life of the activity generating the discharge(s)? 10 years. <br /> Page 7 of 8 - Revision 2/2021 <br />