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lard Industrial Classit~ion (SIC) Code(s) for this facility. (In~e up to four, in order of importance.) <br />~. Receiving Stream: The name of the receiving stream(s). (If disrbazge is to a ditch or storm sewer, also include the <br />name of the ultimate receiving waters.) <br />6. Describe the industrial activities which take place on site, p1 ~h~ " ~ •r ° 5 "~ '/ ~' cc. ti d cam, n ~c.t ti~ - <br />'J <br />7. Other Environmental Per~ttits: 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 # <br />a) Colorado Dischazge Permit System (CDPS or NPDES) <br />b) Colorado Mined Land Reclamation Boazd <br /> <br />- ~ />1- SG,- /D~ <br />If Yes. include MLRB permit amiversary date ~ - ~/ - ~ 5~ <br />8. STORMWATER MANAGEMENT PLAN <br />A Stormwater Management Plan (SWMP) shall 6e prepared prior to application for 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 Appendu A of <br />the application, has been prepazed for my facility. Based on my inquiry of the person or persons who manage <br />the system, or those persons du•ectly 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 aze significant penalties for falsely <br />certifying the completion of said SWMP, including the possibility of fine and imprisonment." <br /> <br />of Permit <br />~~ < ~ f. <br />Name (printed) <br />9. Signature of Applicant pegally responsible person) <br />Date Signed <br />!~` <br />Title <br />'[ certify under penalty of law that I Gave personally examined and am familiaz 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, I believe that the information is true, accurate and complete. I am awaze that there aze <br />significant penalties for submitting false information, including the possibility of fine and imprisonment.' <br />7 7 ~ ~ <br />e of Permit Applicant ~ ~ <br />Date Signed <br />Name (printed) Title <br />7/93/eg -2- <br />