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7.Other Eoviroameatal Permib: Don this ficility atrrmaly have aml mvira®rtQal pettrrhs, ar u it subjeetto . <br />rtgulatian, undo airy of the following progtams7 <br />No Yes Penrrit. <br />a) Colorado Discharge Permit System (COPS or NPDFS) ~-_ <br />b} Resource Conservation and Recovery Aa (RCRA) ~_ _ <br />c} Colorado Divisiar< of Minerals and Geology {fonneriy MI.RD) _~ Sundav M-77-Z85 ~~ <br />Topaz M-80-05'iHR: Carnation M-77-416• St Jude M-78-0SSHR_ Burro M-77-297 <br />d) Superfund Anumdmems and Reauthoriution Act(SARA), Title III <br />(Fsnergency Pl;uuurrg and Comnruaity Right-to-Know Aa), Section 313_x, _ j _ ' <br />- If Yea, is the facility subject to reporting requirements for (circle; applicable) <br />any water priority chemicals under SARA Title III, Section 313 ? _~ Chemicals in Appendix A) <br />8. Group AppGeant:t: Are you currently participating in a stormwarer group application with EPA? ' <br />No ~ Yes Group Applicatinn Number 569 <br />9. SPECIAL REQUIREMENT Stormwater Management Plea , <br />a) Licht indtrrtria! faeilitia, and metal mining facilities: for new facilities (beginning operation after Octaba 1, , <br />1992), or existing facilities applying a$er May 1, 1993, a Stormwatet Maoaganent Plan (SWMP) shall be <br />Prepared prior to applying for wverage under the general pemit, and the foiiowmg certification signed. See <br />Appendix C of the application for a listing of neussary SWMP nequiremmtr. <br />"I certify ua.der penalty of !aw that a complae Stormwater Maaagernem Plan, incompliance with Append'oc C of <br />the application, has been prepared for my facility. Hued oa my inquiry of the person or persona who manage <br />the system, or those person directly responsible for gathering the infomratioq the SWIG l+, to the beu of ray ' <br />Imowledge and belief; true. accurate, and ceanplete. I am aware that there ate sigtificant peaaltin for falsely <br />certifying dtt completion of said SWMP, including the possibility of fine and imprisonment." <br />NA <br />Signature of Permit Applicant Date Sided <br /> <br />Name ~prurted) Title <br />b) Heavy ind.ustrisl facilities: for new facilities (beginning operation after October 1, 1992). or existing facilities' <br />applying after Juae 1, 1993, the pemrittee shall subma a completed SW[vip w the Division with the permit <br />applitarirnt. See Appendix C for a listing of net:essary items under this requiraneat ' <br />SWMP enclosed _,[_,,No _,Yes <br />10. Si~rattrrt: of AppGeant ' <br />"I certify under Penalty of law I have personally exaatinod and am familiar with the information submitted in <br />this application and afl ~**~~~~++~ and that, based an my inquiry ofthose individuals immediately responsible for' <br />obtaining the: infotmatioq I believe that the information is true, accurate and complete. I am aware there ate <br />significant p'maltin for submitting false infom~atioq including the possibility of fine and imprisonment." <br />_~ giso~92 ' <br />Signature: of 't Applicant Date :iigned <br />Richard A. 'VartHorn. Dirt:ctor of Qpy~ians ' <br />Name (printed) Titles ' <br />Page 2 <br /> <br />