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.. . <br />4. Standard Industrial CLtssification (SIC) Code(s) for this facility. (include up to four, in order of importance.) <br />a) tL.6ll b) 1449 C) 1446 d) 1490 <br />5. Receiving Stream: The name of the receiving stream(s). (If dischazge is to a ditch or storm sewer, also include the <br />name of the ultimate receiving waters.) N o streams o r ditches ace o n site . <br />6. Describe the industrial activities which take place on site. s h ov e i /Haul m u s t l y off site <br />Materials will be used for roadbase. <br />7. Other Fnvironmrotal Permits: Does this facility cntrcetly have any environmental permits, or is it subject to <br />regulation, under either of the following programs? <br />No Yes Permit # <br />a) Colorado Dischazge Permit System (CDPS or NPDES) _ _ <br />b) Colorado Mined Land Reclamation Boazd _ x <br />If ~, include MLRB permit anniversary date o c t. 4, 2 0 0 3 <br />8. STORMWATER MANAGIII4IIVT PLAN <br />M-99-024 <br />A Stormwater Management Plan (SWMP) shall be prepared prior to application for coverage under a general <br />permit, and the following certification signed. See the SWMP requirements in Appendu A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendnt A of <br />the application, has been prepazed for my facility. Based on my inquiry of the person or persons who manage <br />the system, or those persons directly responsible for gathering the information, the SWMP is, to the best of my <br />knowledge and belief, true, accurate, and complete. I am aware that these aze significant penalties for falsely <br />certifying the completion of said SWMP, including the possibility of fine anti imprisonment." <br />'/~>~03 <br />Signature of Permit Applicant <br />Date Signed <br />Name (printed) Title <br />9. Signature of Applicant pegally responsible person) <br />"I certify under penalty of law that I have personally examined and am familiaz with the information submitted in <br />this application and all attachmems and that, based on my inquiry of those individuals immediately responsible for <br />obtaining the information, I believe that the information is true, accurate and complete. I am awaze that there aze <br />significant penalties for submitting false information, including the possibility of fine and imprisonment." <br />`f /7 /03 <br />Signatt,ure of Permit A~p~plicant U Date Signed / n <br />1" ~R~'EfEGt7 V/iG,O~Z-. ~OlfCl's [~.C1C~AE CO~vr~JhIANCE KE,~. <br />Name (printed) ttie <br />7/93/sg _Z_ <br />