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<br />.icNERAL PERMIT APPLICATION <br />' STORMWATER DISCHARGES RECE~VE~ <br />AssocIATED wrrH ~,y 15 1998 <br />SAND AND GRAVEL PRODUCTIO <br />OPERATIONS (AND OTHER ~~vision of Mmerais & GeoWgY <br />• NONMETALLIC 1VQNERALS <br />EXCEPT FUEL) '~~~ <br />(Permit Nb. COG-500000) <br />Who is applping for the perr.,it? ~ Owner ^ Operator <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />l . Is this the correct application for your faaGty?? This application is only for the discharge of stormwater. <br />Do you discharge any of the following process generated wastewaters from your facility? <br />No ^ Yes Product wash waters <br />No ^ Yes Mainte.oance/equipment wash waters <br />No ^ Yes Traas rtwaters e. ~ ~i ~\i ~~ ~~~ <br />po (g., slurries) <br />~~''pp~~ a ,..,.. <br />LpJ No ^ Yes Scrubber waters (crashers or classifiers) '• , ,. <br />No ^ Yes Mine dewatering (groundwater aadlor runoff from the mine) <br />If you answered ~ to any of these questioas, do not complete this application. You must instead complete the <br />Process Water and Stormwater Discharges Associated with Sand and Gravel application for this facility, which is <br />available from the Division. <br />2. Name and address of permit applicant: <br />Company Name: o r t /~~~ S ~ ~; ~~ ~, <br />Federal Taxpayer (or Employer) ID>Y: J i ~ ~ 1 <br />Mailing Address:_ <br />City, State and Zip <br />Phone Number: / / r< - <br />Local Contaa (familiaz with facility): <br />Title: the! <br />3. Location of the faality: <br />Sweet Address: <br />City, State and Zip Code: <br />FOR AGENCY USE ONLY <br />Certifintion Number <br />C O G- 5 0 <br />Date Received Fee Category <br /> <br />Year Month Day <br />Phone Number: (7 I ~( ) 2 5 ~ _ z Z 3 , <br />County: (;-~,:,, , ~~ U Name ofi facility: ~ / <' ~ `, r / 1. ~--~/ I %. / rY /d ~ / / <br />Legal Location (Township- , R eg ,section, 1!4 section): ~ =~ ~/ ~~u~~ ~,~ ~ ,~~ ~-a •~-~ <br />Latitude and Longitude: ~ ,, - ' <br />Type of Facility: ~ ~ New (beginning operations after 10/1/92) ^ Existing (as of 10/1/92) <br />s <br />i <br />7/93hQ -1- <br />