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ENERAL PERMIT APPLI~'ION <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC 11~NF~i <br />EXCEPT FUEL) <br />(Permit No. COG-500000) <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />1. Is this the correct application for your [atSGty?? This application is only for the dischazge of stormwater. <br />Do you dischazge any of the following process generated wastewaters from your facility? <br /> No ^ Yes Product wash waters <br />® No ^ Yes Maintenance/equipment wash waters <br />n <br />l~iJ No ^ Yes Transport waters (e.g., slurries) <br />® No ^ Yes Scrubber waters (crushers or classifiers) <br /> No ^ Yes Mine dewatering (groundwater and/or runoff from the mine) <br />if you answered Y~ to any of these questions, do not complete this application. You must instead complete the <br />Process Water and Stormwater Disrltarges 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: ~ -m ~ N ~ "/ C~ P G"` <br />Federal Taxpayer (or Employer) IDav: ~ `I- 0 1 / 7 ~ L 9 <br />Mailing Address:' o u 3 ~~ <br />City, State and Zip Code: N~<<~» , ~ U ~ ~ ~~ o $~yJ `~ <br />Phone Number: (303 1 ~6U-7P / y! Who is applyidg for the permit? ^ Owner ®Operator <br />Local Contan (familiaz with facility): 171 ~ ~ h t~ a ~ 171 o n 1? C- <br />Title: 1'r e ~ i ~ a n.~ Phone Number: (3C 3 ) S~ y - 78 / `~ <br />3. Location of the facility: <br />Street Address: a ~') O P `~ C're v k R o ~} d 2~ a- r( (Q 3 ~/ <br />City, State and Zip Code: ° "' ~ / <br />county: srl,u 171; , ,~ P I <br />Legal Location (Township, Range, <br />Latitude and Longitude: ? ~ ~ S7 <br />FOR AGENCY USE ONLY <br />Certifica4oa Number <br />C O G- 5 0 <br />Date Received Fee Category <br />Year Month Day <br /> <br />u1•Sb <br />Type of Facility: ^ New (beginning operations after 10/1/92) ~ Existing (as of 1011/92) <br />Name of facility: _ <br />section, 1/4 section): <br />n •' <br />-~oSec- <br />7/93/sg -1- <br />