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:'r W�R 4 ? ' Pyr _C j •CN JA <br /> Al <br /> ?GR aG-M CY SSE CNL? <br /> 3TGR MW--iI�i DISC_EARGES { <br /> l� ^�nc,riOn!�TRIDner I <br /> DPIXM_A,MGNS ixUq'D OT 1ER 1 f Iw Z.! Vea 7q-- C=Awy , <br /> ?TC3NNE iALLIC �e <br /> 'Mr FUEL)_.>�.b � <br /> `t=, ?io. CCG-50=) <br /> 3Sease print or type_ Do apt sne=t ro complete this :orm before rending y.e inam,ri . <br /> _. Is this the carrl+a anoiicadoo for -our facility:? —73 , am iCaIIOn 3 �]niy Mr*he QMc7arge of 3tor;trw33ar. <br /> Do +ou discharge nay of the :oilowing Xoc`5s gencrared •Na=,vatera `cem -7CUr tacuit"? <br /> �A No ❑❑ ?es Pr'adua-Hash -:va;ets <br /> No IIainmaazr-,eauipme.SL waaa watt= <br /> J No a as '7--=tort Irarers le.a., UUM.es) <br /> L2 Pip ❑ 'I-^ Sczubber ease.- (c.-shers or <br /> rRio :'-3s Mine dewaattng ;toundwater and/or rmar'from me mines <br /> if you mswered Ym m any of tese questions, do act eowoiete ibis application. ,'ou m= instead c:mgiete :he <br /> Process Rater and Storatwater Msd=ges Associated with Saud and Gravel =lica[ion ;:,r Ais �caity, -vni= s <br /> available -=M he Division. <br /> Name and addreas of pvimit applicant: <br /> Company Name Ii d County Public ;works <br /> federal'?axnaye !or rmnioyeri IDc: 7 i 6 0 0 0 8 3 <br /> Mailing Address: D .O. Box 758 — — — — — <br /> Civf, State and Zip Cade: <br /> Greeley, CO 80632 <br /> Phone Number f 970 ) 356-4000, A3750 F <br /> Who is awlving for ffie permit? i Owner ' -" Coerator <br /> Local Comact (lvmiliar with tacit Grp; Nelson <br /> Title: Hiving Supervisor PhoneNuwoer: ( 970 ) '356-4000, Ext. 3750 <br /> I.ocadon of the iaciiitT <br /> Screer address: WCR 13 apbroximateiv 1/2' mile south of WCR 62, east side of 4CR 13 <br /> Ciry, State and Zip Cade: W+ndsor, CO <br /> County: t1eld flame of 1kil ty: Lind Borrow Pit <br /> Lzgai :.ac=on (T_otvaship, Range, section. V4 ectioaj: Sec . 6. T5cT. R67 4. > T 1 <br /> Ladtade and Loner mde: Lac . 1�10 25 ' Lone. 10L 55' <br /> r^ <br /> T<Tpe of Facility: j_'� New ,beginning mPe:auons .nt= ?0/1192) L r' r:.isdn, ?as of io/1f5Z1 <br />