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4. Standard Industrial ClassificationC) Code(s) for this facility. (Include u0 four, in order of importance.) <br /> a) 1420 b) 40 c) 1499 d) <br /> Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the <br /> name of the ultimate receiving waters.) Colorado River <br /> 6. Describe the industrial activities which take place on site. Rip/Rap Mining <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 Discharge Permit System (CDPS or NPDES) X _ <br /> b) Colorado Mined Land Reclamation Board _ <br /> If Yes, include MLRB permit anniversary date <br /> 8. SPORMWATER MANAGEMENT PLAN <br /> A Stonmwater Management Plan (SWMP) shall be prepared prior to 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 prepared 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 /> knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for falsely <br /> certifying the completion of said SWMP, including the possibility of fine and imprisonment.' <br /> Signature of Permit Applicant Date Signed <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 familiar 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 aware that there are <br /> significant penalties for submitting false information, including the possibility of fine and imprisonment:' <br /> Signature of Permit Applicant Date Signed <br /> • Name (printed) Title <br /> 7/93/sg -2- <br />