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4. Standard Industrial ClassiFuation (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />a) ~ ~ ~ ~ bl c) d) <br />5_ Receiving Stream: The name of tAh(e receiving stream(s). (If d-is-c/h'arge is to a ditch or storm sewer, also <br />the uhimate receiving waters.) ~S ~~1~~ ~jl.~x4( ~/{~1'fG')GYi~! r1T~~~, ~ <br />6. Describe the industrial acfivities which take place on site. <br />name of <br />7. Other Envuonoledtal Permits Does this facility currently Lave any enviromrtental permits, or is it subject to regulating <br />under either of the following programs? <br />a) Colorado Discharge Permit System (CDPS or NPDES) <br />b) Colorado Mined Land Reclarnation Board <br />If Yes, include MLRB pe;rtnit anniversary date <br />8. STORMWATFR MANA(~3KaH'I' PLAN <br />Nn Ves Permit # <br />-y <br />- ~°` ,./d <br />A Stormwater Management Plan (SWMP) shall be pr~ered prier to application for coverage under a general permit, and the <br />following certification signed. See the SWMP requirements in Appendix A. <br />"1 certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of the <br />applicatioq Las been prepared for my facility. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathering the information, the SWMP is, to the best of my Imowledge and belief, tme, <br />accurate, and complete. I am aware that there are significant penalties for falsely certifying tLe completion of said SWMP, <br />includitg the possibility of fine~and imprisonment." <br />Applicant <br />9. Signature of Applicant (legally responsible person) <br />ll.~ <br />Date Signed <br />Tide <br />"I certify under penalty of law tLat I have personally examined and am familiar with the information submitted in this application <br />and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I <br />believe tLat the information is true, accurate and complete. I am aware that there are significant penalties for submitting false <br />inforrnatioq including the possibility of fine and imprisonment." <br />Signature of Pemnt Applicant <br />Name (printed) <br />7/93/sg <br />~IU- 2 <br />Date Signed <br />?_ <br />Title <br />