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4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />a) 1470 b) 1440 c) <br />d) <br />5. Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the name of <br />[he ultimate receiving waters.) tj~'.g}~Percul anon rate for this area. Poteni al fnr ctnrmx•,aters <br />to dls bare in , k di h. Ar ancaa Rive nl ima a rant>i ,ing o-~atar „ndergrot <br />The Trout Creek Ditch does not drain into the Arkansas but infiltrates in the fields. <br />6. Describe the industrial acNvlNea which take place on site. <br />ACtlVi ties o h' i in 1 ,d b ac inoyt) ran ma a ial nd cnrtin~ <br />material. <br />7. Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to regulation, <br />under either of the following programs? <br />Nn Ves Permit # <br />a) Colorado Discharge Permit System (CDPS ar NPDES) X _ <br />b) Colorado Mined Land Reclamation Board _ ~ M2001-035 <br />If Yes, include MLRB permit anniversary date SeDtHnber 19th <br />8. STORMWATER MANAGEi1'IENT PLAN <br />A Stortrwater Management Plan (SWMP) shall be prepared prior m application for coverage under a grneral pertni; and the <br />following certification signed See the SWMP requirements in Apprndrx A. <br />C "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 ditecdy responsible for gathering the information, the SWMP is, to the best of my knowledge and belief, tme, <br />accurate, and complete. I stn aware that there are significant penalties for falsely certifying the completion of said SWMP, <br />including possibility of fine and imprisonment." <br />Signature of P pplicant Date Signed <br />Lon Hollenbeck Praaidanr <br />Name (printed) Tide <br />9. Signature of Applicant (legally responsible person) <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application <br />and all attachments and tha; based on my inquiry of those individuals immediately responsible for obtaining the information, I <br />believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonmrnt." <br />Signature of Pemrit <br />/w <br />Date Signed <br />.ion Hnllanhark President <br />Name (printed) Tide <br />7r9srss -2- <br />