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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM <br />APPLICATION FOR PERN IT TO DISCHARGE - SHORT FORN <br />MUNICIPAL, INDUSTRIAL <br />FOR ENCY USE <br />4PPL1 TION NUMCiER <br />DATE RECEIVED <br />YEAR M0. DAY <br />Do not attempt to complete this form before reading [he accompanying instructions <br />Please print or type <br />1. Name, address, and telephone number of the owner of [he facili[Y producing <br />discharge. <br />A. Owner Coulson Excavatinn Co., Inc. <br />B. Foci l i ty name B rownwood P i t <br />c. Nailing address 3609 North County Road 13 <br />o. cicy Loveland D. state Colorado <br />E. cpuntr Lorimer F. Zip Code 80537 <br />G. telephone Number ( 303 ) 667-2178 <br />Area Code <br />2. Locaclon of facility <br />A. Legal brief descr(ptlon W. 1/2 of Sec. 19, T. 5N. , R. 694J. , <br />B. street Access from State Highway 402 <br />c. cicy Loveland D. Councr Lorimer <br />E. scaceColorado <br />F. Telephone Number (303 ) 667-2178 <br />Area Code <br />c. Lpcal contact C. H. Coulson or Richard L. Coulson <br />). Sanitary discharges (only for sewage treatment facilities) <br /> n/a <br />A. Unit treatment proces3es utilized <br />B. Design flow (average daily) of facility n/d NGD . <br />C. Percent BOD removal (actual-previous year ) n/d <br />D. Population served n/d <br />E. Number of discharge points n/d <br />F. Description of discharge location(s): n/d <br />G. Name of receiving water(s): n/d <br />N. Is land application used or planned? n/a <br />I. Method of sludge disposal n/a <br />J. (1) Do you receive indusCrial was[e7 n/a <br /> (2) If yes, describe the sources n/a <br />6tn P.r~. <br />K. A[[a ch any laboratory analyses of your effluenC quality n/d <br />