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GENERAL PERMIT APPLICA'T'ION <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH <br />SAND AND GRAVEL PROllUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC MINERALS <br />For Agency Use Only <br />COG-5 0 <br />Received: <br />Year Month Day <br />EXCEPT FUEL) <br />(Permit No. COG-500000) <br />Please print or type. Do not attempt to complete this form before reading the insvuctions. <br />I . Is this the correct application for your facility?? This application is only for the discharge of s[ormwater. <br />Do you discharge any of the following process generated wastewaters from your facility? <br />No ^ Yes Product wash waters <br />No ^ Yes Maintenance/equipment wash waters <br />No ^ Yes Transport waters (e.g., slurries) <br />No ^ Yes Scrubber waters (crushers or classifiers) <br />No ^ Yes Mine dewatering (groundwater and/or rwtoff from the mine) <br />If you answered Yes to any of these questions, do not complete this application. You must instead complete the Process <br />Water and Stormwater Discharges Associated with Sand and Gravel application for this facility, which is available <br />from the Division. <br />2. Name and address of permit applicant: <br />Company Name: <br />Federal Taxpayer <br />Mailing Address: <br />City, State and Zii <br />Phone Number: C~1 f1 1 (s(0~ -~ _J'7~i Who is applying for the permit? <br />Local Contact (familiar with facility): <br />Title: <br />Operator <br />3. Location of the facility. <br />Street Address: , , .~ v <br />City, State and Zip Code: G1nYP,n(v _ ~~ ~~aa~ <br />Cotmty: ~_ Name of facili ' <br />Legal Location (Township, Range, section, 714 section): <br />Latitude and Loneitud~j~~ ~Q° 9~r 15 i,.R" /.. l\ Ir~'od ~ <br />l'ype of Facility: ~ New (beginning operations after 10/1/92) ^ Existing (as of 10/1/92) <br />nlJBisg <br />