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GENERAL PERMIT APPLICATION <br />STORMWATER DISCHARGES For Agency Use Only C O R - 0 4 `_ _ <br />ASSOCIATED WITH <br />METAL MINING (Permit No. COR-040000) (and <br />some Coal Mining -see Instructions) Date Received: _ / _ _ / _ _ _ _ <br />Month Day Yea <br />ALL APPLICANTS MUST FOLLOW THE DIRECTIONS FOR COMPLETION OF THIS FORM IN <br />PART C OF THE INSTRUCTIONS <br />Please print or type. All items must be completed accurately and in their entirety or the application will be deemed incomplete <br />and the application returned. Processing of the application wi[I not begin until al] information is received. Please refer to the <br />instructions for information about the required items. Original signatures for Items 7 and 8 are required. <br />1. Name and address of the permit applicant: <br />Company Name LKA International Inc <br />Mailing Address 3724 47th street, ct. Nw <br />City, State and Zip Code cig xarbor, wa 98335 <br />2. <br />Phone Number (zs3 ) 851-7486 <br />Local Contact (familiar with facility) <br />Title ~r~ect scientist Phone Number (970) 565-1222 <br />Local Contact E-mail Address kkingQgaultgroup. com <br />Legally Responsible Person (application signer) E-mail Address abeco@comcast. net <br />Location of the Facility: <br />Street Address 2.6 miles SE of Lake City, C0: Section 10: Township 3N: Range 004W: Qtr NE _ <br />City, State, and Zip Code Lake city, co elz3s <br />County Hinsdale Name of Facility Golden Wonder Mine <br />Latitude/Longitude -use one of the following formats <br />Latitude 3 a / o o/ 1 5 Longitude 1 0 ~/ 1 6/ s 3 w (e.g, 39°42' 11", 104°55'57") <br />degrees minutes seconds degrees minutes seconds <br />-or- <br />Latitude . _ - _ Longitude _ _ _ . _ _ _ (e.g., 39.703°, 104.933°') <br />Who is applying? OwnerX Operator <br />degrees ([0 3 decimal places) <br />3. <br />4. <br />degrees (to 3 decimal places) <br />Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to three, in order of importance.) <br />a) 1041 <br />c) <br />Permit Category: Under which mining category does this facility belong? (See Appendix A.) <br />X Metal Mining <br />Mine Category: Which category is your facility under? <br />X Active mine, less than 10 acres Active mine, 10 acres or more Inactive mine <br />Colorado Division of Reclamation, Mining and Safety Permit Number (if applicable): N-1978-091 <br />b) <br />Coal <br />3/07/MM 1 oft <br />