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olorado Department of Public Health & Environment FOR AGENCY USE ONLY <br />Water Quality Control Division <br />WQCD-P-B2 REC <br />4300 Cherry Creek Drive South EFF <br />Denver, Colorado 80246-1530 YEAR MONTH DAY <br />INACTIVATION NOTICE FOR <br />MINING STORMWATER DISCHARGE GENERAL PERMIT CERTIFICATION <br />Please print or type. Form must be filled out completely. <br />Certification Number: COR-04 O ~ O Y Taxpayer ID or EIN ~ $' D ~ ~ ¢ ~ 3 y <br />--OR-- COG50 <br />Permittee(Company)Name: Cu(uRR'Eo l7i~rsr„/ aF /"fin-ca~tls f- G-culoGS <br />Permittee Address: /.3 t 3 •S /~ G 2 ~'7/f~ S~ t ~ T" /lam oh a~-- / f <br />~e.vvtti. cvlo2/~Ydn $'uLa3 <br />Mine/FaciliTy Name: ~ y.t ( /~i?Sr ~v i`7 r ti c /'moo n-r(. ~ t [ G /fM~ Tr u n.i <br />Mining Site Address/Location: C= ~-d ~ ~ G'r..4-/ c?~. rr Flvit d. y 4 ~`+'r r~s w ~ ST <br />d~ pcds ro~-c Real STO~t Cv/ult.4-~!o Ff /l J-3 <br />County: /fir T h r ti Contact Person: .STt ~ t w !c s n, ... e 2 <br />Reason/justification for inactivation, and description of final site stabilization. (Attach any supporting documentation, such <br />as proof of Mined Land Reclamation Boazd bond release): <br />eL <br />e <br />I certify under penalty of law that by the date of my signature below, all disturbed soils at the identified mining site have <br />been finally stabilized; all temporary erosion and sediment control measures have been removed; all mining and equipment <br />maintenance waste have been disposed of properly; and all elements of the Stormwater Management Plan have been <br />completed. <br />I understand that by submitting this notice of inactivation, I am no longer authorized to dischazge stormwater associated <br />with mining activity by the general permit. I understand that dischazging pollutants in stormwater associated with mining <br />activities to the waters of the State of Colorado, where such dischazges aze not authorized by a CDPS permit, is unlawful <br />under the Colorado Water Quality Control Act and the Clean Water Act. <br />I certify under penalty of law that I have personally examined and am familiaz with the information submitted herein, and <br />based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information <br />is tme, accurate and complete. I am awaze that there aze significant penalties for submitting false information, including the <br />possibility of fine and imprisonment. (See 18 U.S.C 1001 and 33 U.S.C. 1319.) <br />Signature of Pemut~~+Applic~Jant (Legally Responsible Party) Date Signed/~ Jl <br />~0/eyicL G J'/~r~PcI0... ~/~'/1-Frr .(/~/PC rV/ <br />