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<br /> <br />;Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />! a) 1442 b) 7951* c) 3273* d) <br />*occasional use by governmental entities <br />~t <br />5. Receiving Stream: The name of the receiving stream(s). (If dischazge is to a ditch or storm sewer, also include the '• <br />name of the ultimate receiving waters.) most rain etc evaporates out of bottom ofD' t _ <br />two ditches divert any run-off water from area and carry water for irrigatic <br />6. Describe the industrial activities which take place on site. Tntarmi rtent vaP by gnyarnmon~ .,f _. <br />mobile asphalt and redi-mix plants; refuse is contained in trash containers <br />provided with collection. .by company <br />7. Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to <br />regulation, under either of the following programs? <br />No Yes Permit # <br />a) Colorado Dischazge Permit System (COPS or NPDFS) x _ <br />b) Colorado Mined Land Reclamation Boazd _ X M-A ~-i ~9 <br />If Yee ,include MLRB permit anniversary date August, 1982 <br />8. STORMWATER MANAGEMENT PLAN <br />A Stormwater Management Plan (SWMP) shall be prepared prior 1o application for coverage under a general <br />permit, and the following certification signed. See the SWMP requirements in Appendix A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of <br />the application, has been prepazed for my facility. Based on my inquiry of the person or persons who manage <br />the system, or those persons directly responsible for gathering the information, the SWMP is, to the best of my <br />Itnowledge and belief, true, accurate, and complete. I am awaze that there aze significant penalties for falsely <br />certifying the completion of said SWMP, including the possibility of fine and imprisonment." <br />of Permit Applicant <br />Date Signed <br />Jacquelene M. Goemmer aka Mrs. L. Otto Goemmer Owner <br />Name (printed) Title <br />9: Signature of Applicant (legally responsible person) <br />"I certify under penalty of law that I have personally examined and am familiaz with the information submitted in <br />this application and all attachments and that, based on my inquiry of those individuals immediately responsible for <br />obtaining the information, I believe that the information is true, accurate and complete. I am awaze that there are <br />significant penalties for submitting false information, including the possibility of fine and imprisonment.' <br />Signature of Permit Applicant <br />Name (printed) <br />04-02-1994 <br />Date Signed <br />Title <br />7/93hg -2- <br />