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. <br /> <br />FOR AGENCY USE ONLY <br />PROCESS WATER AND <br />DISCHARGES ASSOCIATED WITH <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC MINERAIS <br />EXCEPT FUEL) <br />Please print/o+r type. Do not attempt to complete this form before reading the instructions. <br />New G or Renewal G If renewal, existing perntit number. CO <br />1. Name and address of permit appl~ant <br />Compmy Name: <br />PERMIT' NUMBER <br />c o - <br />DATE RECEIVED <br />YEAR MONTH DAY <br />TYPE: P S <br />Federal Taxpayer (or Employer) ID#:~ ~ _ ~ 3 ,~. _S ~ {~ (~ <br />Mailing Address : aG `y SN.p u 5 ~ k^ - ~ L ~f+f21~ ~ytk n <br />City, Stale and Zip Code: ~~ff tJ tl l .S~tJi W ~ / oC3Q <br />Phone Number: (~ .~. 1 ~ri Y ~~ ~~/~Cp ~ I <br />Local Contact (familiar with faciliryk~'.] ~`1 G V GI ZS ~ ~~ Title!? ~ S 1 GI 4r N ~ <br />Phone Ntmrber. (R~~' 1 ~ ~ / ~ ~~~ Faz No.: (x''70 1 /n ~ / - , j~rj ~,~ <br />Who is applying for the permit? V Owner V Operator <br />2. Name and address of property owner. <br />Mailing Address <br />City, State and Zip Cffode : /~(~/ pJ Nr~/ ~ ~y ~ ~ ~ ~ I ~ _3 6 <br />Phone Number : (~%U l (~Lf 1 ~ l / / .~ Fax No.: ( 1 <br />-c <br />3. Location of the facility: <br />Street <br />City, State and Zip Code: ~IA tJ n) / ~O 1J~ ~ ~~61 ~ ~ yy ~-t <br />County: 6u N N) e~ ~ Name of facility: S~r/l,~~t0'Q 6 ~' '/'/~~ cam( 'l , } <br />Legal Location (Township, Range, section, 1/4 section):T~f q IV ~ ~_ C 1/~ SF.GT/CON ~(i(„J' <br />Latitude and <br />~~ <br />