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~. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to tour, in order of importance.) <br />a) t t~ U 7~ b) <br />c) <br />d) <br />3. Receiving Stream: The name of the receiving sirearn(s). (!f discharge is to a ditch or storm sewer, also include the Warne <br />of the ultimate receiving waters.) ~-~~t'~C~ SCCLt ~~b12, CCPP K. YY)Olsl YQ (Q 1 V(', p~~CL~{-~ 1 u~ <br />l_~OL~C( iUf3l~O(~ -Ft'oirt AYltlr~ G~l(J-./~rrny Corp c~ .Exrn~e~5 <br />6. Describe the industrial activities which take place on site. I l 111V~t1 ~~LYId (`,LYI (( (/~VL1 YP I t tUYrj <br />_~l ~~ <br />7. Other 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 # <br />a) Colorado Discharge Permit System (CDPS or NPDES) - i~O <br />b) Colorado Mined Land Reclamation Board -- I tl QCOCt?Srj <br />If Yes, include MLRB permit anniversary date <br />8. STORMWATER MANAGEMENT PLAN <br />A Storrnwater Management Ptan (S WMP) shall be prepared prior to application for coverage under a general permit, and <br />the following certification signed. See the SWMP requirements in Appendix A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of the <br />application, has been prepared for my facility. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathering the information, the SWMP is, to the best of my knowledge and belief, <br />true, accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said <br />SWMP, including the possibility of fine and imprisonment." <br />~gnature o ermit Applicant Date Signed <br />\ ask ~ ~ E E~\E o ~ v<F <br />Name (printed) Title <br />9. Signature of Applicant (legally responsible person) <br />"f certify under penalty of law that 1 have personally examined and am familiar with the information submitted in this <br />application and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the <br />information, f believe that the information is true, accurate and complete. [ am aware that there are significant penalties for <br />submitting false information, inctud <br />the possibility of fine and imprisonment." <br />,a6~ o~ <br />ature of Pennif pp(~l cant \\ Date Signed <br />Natne (printed) Title <br />:dvsr,~ -2- <br />