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~i -~;-:.~~- <br />,v. 5lttndar~.t lnditstrtaF Clessilica~iC) Code(s) for this facility. (Inclu~o four, is order of importance.} <br />:; <br />a) / ~ ~~ b) <br />c) <br />d) <br />5. Aect;ivlr~g Stream: The name of the receiving stream(s). (If discharge is to a ,ditch or storm sewer, also include the <br />name of the ultimate receiving waters.) ~~Ytc~~AfLrr v ~u~ C~ <br />- 6. Uescrih~ the industrial activities which lake place on site. <br />7. Qlltcr 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 Jl <br />a) Colorado Discharge Permit System (CDPS or NPGES) X _ <br />b) Colorado Mined Land Reclamation Boazd _ ~ //f ' fi`r`- ~ ~ 9 <br />If Yes, include MLRB permit anniversary date .~~v /~ <br />8. STOIii•1'4VATER MANAGEMENT PLAN (•do not fill out unless required, as discussed in the Instruaioas) <br />For those facilities specified in the Instructions only, a Stormwater Management Plan (SWMP) shall be prepared <br />prior to applying for coverage under a general permit, and the following certification signed. See the SWMP <br />requirements in Appendix A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A c <br />the application, has been prepared 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, ac rate, and complete. 1 am aware that there are significant penalties for falsely <br />cerlityiag-f}te omelet n of d SWMP, including the possibility of fine and imprisonment.' <br />7 Lao X93 <br />~gnatu- re~Per~m]t- /p'li f nt Date Signed ' <br />r2.L( J 'Lln {ytG ~Z ~resr ~Pnt -_ <br />9. Signatt,re of Applicant <br />' "I certify under penalty of taw that 1 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 fo: <br />obtaining the information, I b~lieve that the information is true, accurate and complete. ! am aware that there are <br />siyt~ificantAenalties~r sut~iitting false information, including the possibility of fine and imprisonment.' <br />lam- res,~1 ent <br />tnrov.g -z- <br />:` 4i~~'r <br />9~ <br />f.P2~:. <br />