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4, Standard Industrial ClassiF•ion (SIC) Code(s) for this facility. (Incl. up to four, in order of importance.) <br />a) N/A b) <br />d) <br />c) <br />5. Receiving Stream: The name of the receiving stream(s). (If dischazge is to a ditch or storm sewer, also include the <br />NJA <br />name of the ultimate receiving waters.) <br />6. Describe the industrial activities which take place on site. N/A at this time <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 rY <br />a) Colorado Discharge Permit System (CDPS or NPDES) <br />b) Colorado Mined Land Reclamation Boazd <br />If Yee, ,include MLRB ppermit anniversary date <br />Operation `1.1')2 is being <br />8. STORMWATER MANAGEMENT PLAN <br />Application for a Limited <br />applie for at t is time. <br />Impact <br />A Stormwater Management Plan (SWMP) sha!! be prepared prior to appliratiort fot 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 prepaed 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 /> <br />2/10/95 <br />Signarure of Permit Applicant Date Signed <br />Cecil C. Powell Owner <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, 1 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 />i <br />Signature of Permit Applicant <br />Cecil C. Powell <br />Name (printed) <br />7/93/sg <br />-2- <br />2/10/95 <br />Date Signed <br />Owner <br />Title <br />