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~ ~ ~ - <br />. ~. Standard Iaduatrial Chtsaiffeatiat (SIC) Codap) for this facility. (include sup to four, in ordu of importance.) <br />5. RecaviaY Strom: The name of the rece~ivi(ng taream(a). N disrbarge is to a ditrb or storm sewn, also inclnnude the <br />none of the ultimate receiving waters.) ~~" -~ e ^ ~ ~ ~ J 9 f r ~ A n~ e~i _/Ti • u N 0 T <br />~.~i/ (.y 4~,'ITir.~ t.avy.'1~,'--'t~.+^~,.~ `» ~[S ~ ;^ ~[onl au~ S ~..~;~ i7 <br />biu g oi. th t,v~ off' Jag /y,vate~ /o r grew.., <br />6. Describe fhe industrial activities which tale platy an wile. rn c k C rK s /~ ,' u ~ ,' s 4 // <br />7. Outer F~tviroommtal Permits: Does this facility currently have any environmental permits, or is it subject to <br />regulation, undo eithu of the following programs? <br />No Yes Permit err 'i ~~ <br />a) Colorado Diacbarge Permit System (COPS or NPDI,.S) .Ql~ _ <br />b) Colorado Mined Land Reclamation Hoard _ ~l~ -l 1 • =% ~~• G 7 ~ <br />3'~ <br />8. STORMWAT]6JQ MANAGF14llEN'P PLAN <br />A Stotmwatu Management Plan (SWMP) s1+aU be pnpand prior to application for covuage tinder a general <br />permit, and the following certificuion signed. See the SWMP requirements in Appendix A. <br />If Y~q, include ML.RB permit amiversary date ~,i'%, n ~: ~ 1 :~ ~ <br />Y <br />'I certify uttda penalty of law that a complae Stotmwata Mauagatumt Plan, in compliance with Appead'u A of <br />the application; hu been prepazed for my fuility. Based on my inquiry of the puson or persons who manage <br />(he system, or those persons directly responsible for gathering the information, the SWMP is, to the best of my <br />Imowledge and belief, true, accurate, and complete. I am aware that there are significant penalties f9 sely <br />certifying the complanon of said SWMP, including the possibility of ~~ ~disopme~ ~,~ ;~ ~ <br />rL~~ v r o Q' <br />Signatue of Permit Applicant <br />Date Signed <br />/~I f.[~~ F Nos~elnu'~.7; ~IJ.'11;,,~ (~a I s~~„ <br />~~ Du.N[r S <br />Name (printed) Title <br />9. Signature of Applicant (legally responsibk person) <br />'I certify ands penalty of law that I Gave personally examined and am familiar with the infiormatiou submitted in <br />this application and all attachments and that, based on my inquiry of those individuals immediately responsible for <br />obtaining the information, l believe that the information is true, accurate and complae. I am awaze that thus ue <br />significant petalties for submitting false informaion, including the possibility of fine and imprisonment.' <br />Signature of Permit Applicant <br />Name (printed) <br />Signed <br />1ro~y _y_ <br />