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ENERAL PERMIT APPL?CAT <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH <br />"'AND AND GRAVEL PRODUCTION <br />.1PERATIONS (AND OTHER <br />NONMETALLIC MII~IERALS <br />EXCEPT FUEL) <br /> <br />AGENCY USE ONLY <br />Certification Number <br />C O G- 5 0 <br />Date Received Fee Cate ory <br /> <br />Year Month Day <br />(Perrot No. COG-500000) <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />1. Is this the correct application for pour facility?? This application is only for the discharge of stormwater. <br />Do you discharge any of the following process generated waztewaters from your facility1 <br />No ^ Yes <br />No ^ Yes <br />No ^ Yes <br />0 No ^ Yes <br />ONo ^Yes <br />Product wash waters <br />Maintenance/equipment wash waters <br />Transport waters (e.g., slurries) <br />Scrubber waters (ctushecs or classifiers) <br />Mine dewatering (groundwater andlor runoff from the mine) <br />If you answered Y~,F to any of these questions, do not complete this application, You must instead complete the <br />Process Water and stormwater Discharges Associated with Sand and Gravel application fot this facility, which is <br />available from the Division. <br />2. Name and address of permit applicant: <br />Company Name: Henson Brothers Aggregate/Benson Brothers Truck S. Eguiyment <br />Federal Taxpayer (or Employer) ID#; 8 4 0 9 5 1 9 3 1 <br />Mailing Address: 2138 J-50 Road <br />City, State and Zip Code: Austin, Colorado 81410 <br />Phone Number: 1 303 1 835-3128 Who is applying for the permit? ~ Owner ^ Operator <br />Local Contact (familiar with facility): T- Fa~a rd npn cnn <br />Title: Partner/Owner Phone Number: ( 303 ) 835-3128 <br />3. Location of the facility: <br />Street Address: 2134 J-50 Road <br />City, State and Zip Code: Austin, Colorado 81410 <br />County: Delta Name of facility: Benson Brothers Agareaate <br />Legal Location (Township, Range, SeCt10n, I/4 SeCtlatl): SRCTTON 3fi. T 14 S. R 95 IJ f1F THR fith Pt <br />LatiNdeandLongi[ude: Latitude 38 47' Longitude 107 58' <br />Type of Facility: ^ New (beginning operations after 10!1!92) ®Existing (az of 10/1192) <br />7/93/~~ <br />