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olorado Department of Public Health & Environment FOR AGENCY USE ONLY <br />Water Quality Control Division _ ~ REC <br />WQCD-P-B2 ~ ~ EFF <br />430D Cherty Ll'eek Dtive South YEAR MONTH DAY <br />Denver, Colorado 60246/530 <br />' ~ NOTICE OF TRANSFER AND ACCEPTANCE OF TERMS OF A <br />STORMWATER DISCHARGE GENERAL PERMIT CERTIFICATION <br />1) To be completed by the NSW permittee: <br />I hereby accept trsasfcr of this Colorado Discharge Permit Certficatien No. CO 6 s ~ L a S ~, which was issued to <br />U.s s eI1 G t2.Anr` ~ P: t . I have reviewed the tams and conditions of tlds pemdt d Stormwater Management <br />Plan and accept full responsibility, coverage and liability. This transfer will be effective on: (S'~/ ~~od <br />The tac(lity site is located at: <br />Street Addiess: I ~ 4 ~! <br />City: C ~ F ~ ~ : n~'o l•. Sm[e: ~.o Zip Code: ~ O .$- ~{ <br />County. J ~2 i M ~ 2 Name of facility or developmenn Qu a.0 E ( W .~ '~ <br />The NEW permittee is: <br />cnmpaay Natae: ~{~ 8• L4.i.. r Ja,r.d/ a v I..AJ E ~ LL L <br />Mailiag.4.ddr`esa: ~ o Q o i4 L a- a 4 <br />City: ()J E~(i r~T'o 7~ Stater C o Zip Code: ~S 0 S y Q <br />Phone No.: (~j`La ) .~C.. ~' `) y.O 3 Fed. Taxpayer (or Employer) ID ~y~ E~ ~r~_ _ _ __ <br />Local Contact (familiar with fam7ity): . t ~ r <br />Title: ~~F S e t:~en,,,'h Phone No.: ~ c a [ -~ - ~ a ~{ a <br />I certify tends penalty of law that I have personally examined and am familiar with the information submitted herein, and <br />based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the <br />infotmation is true, accurate and complete. I am aware tbattbere are significant penalties for submitting false information, <br />including the possibility of fine and imprisonment. ~ . <br />L <br />2) To be completed by the Previous permittee: <br />Aa previous permittee, I hereby agree to the transfer of the above referenped permit and certification and ail responsrbilities thereof. <br />Company Name: f . <br />Mailing Addres ~ r <br />City. State: I Q Q~ Zip Code: <br />Phone~rp~ /7 Fed. Taxpayer (or Employer)ID:_________ <br /> <br />Page 33 <br />