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OR AGENCY USE ONLY <br />PROCESS WATER AND STORMWATER PERMIT NUMBER <br />DLSCHARGES ASSOCIATED WITH <br />C <br />O <br />- <br />S <br />ND AND GRAVEL PROD <br />TION <br />A <br />UC <br />OPERATIONS (AND OTAER DATE RECEIV ED <br />NONMETALLIC MIlVIItAI S <br />EXCEPT FUEL) <br /> <br /> YEAR MONTH DAY <br /> TYPE: P S <br />Please rint or type. Do no/t attempt to complete this form before reading the instructions. <br />New or Renewal G If renewal, existing pemut number. CO <br />1. Name and address of permit applicant: <br />Company Name: <br />G Owner Operator <br />Federal Taxpayer (or Employer m#: ~. <br />Mailing Address <br />City, State and Zip <br />Phone Number: (~~3) l 05~ ' ~I,CIV <br />Loca] Contact <br />Phone Numbe <br />Who is applying for the permit? <br />2. Name and address of property owner. <br />Mailing Address <br />Fax <br />City, State and Zip Code : _ 1/p~(111P~~ l ~ i)~~~`l <br />Phone Number : {303 1 $63 - $ I S `/ Faz No.: ! ,.b3 1 839 - S37L <br />3. Location of the facility: <br />Street <br />City, State a/~nd Zip Code:~P/)~~ ~/" 58'n ~~ ~,/~ ~ /©~~j~~l ~ l11 <br />County: ?`f/d,Q.iMS Name of facility: / 1['1 ~' 1~{t'I-T ? n /~/ <br />Legs]Location(Township, Range~~jjsection,l/4 section,),: ~C. 7-~~~K'c. JI~j~1-~d J~i\ /11D~~.1~ <br />Latitude and Longitude: ~C'^'~1~o'~~rr'~1 i0 `p~~,'~+" t 1/UJ <br /> <br />