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aI a}' <br />.-s <br />": u .. <br />6.; DeSCrlhe the lndnStrlal activitleS which take plalx On site. Earth moving. Gtream channel rerun ctrurtiny,; <br />Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to <br />regulation, under any of the following programs? <br />a) Colorado Discharge Permit System (CDPS or NPDES) <br />b) Resource Conservation and Recovery Act (RCRA) <br />- If Yes, is your facility a Treatment, Storage or Disposal facility? <br />c) Colorado Division of Minerals and Geology (formerly MLRD) <br />d) Superfund Amendments and Reauthorization Act (SARA); Title III <br />(Emergency Planning and Community Right-to-Know Act), Section 313 <br />No Yes Permitff or ID{t <br />_ ~ rnnnnn ~g~ ~ <br />x <br />x <br />x <br />NOTE: Both Items 8 and 9 must be signed in order far the application to be processed. <br />8. S;ormwater Management Plan <br />a) Heavy Industry, Light Industry, Mining: a Stormwater Management Plan (SWMP) shall be prepazed prior to <br />applying for coverage tinder a general permit, and the following certification signed. See SWMP requirements in <br />Appendix B (Light and Heavy Industry) or Appendix C (Mining). <br />"I certify under malty of law that a wmplete Stotmwater Management Plan (SWMP), in wmpliance with <br />Appendix ~,~C (circle one) of the application, has been prepazed for my facility. The SWMP was prepazed <br />under my direction or supervision and with a system designed to assure that qualified personnel properly gather <br />and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, <br />or those persons directly respotzsible for gathering the information, the SV/MP is, to the best of my lmowledge <br />and belief, true, accurate, and complete. I am awaze that there aze significant penalties for submitting false <br />information, including the~bility of fine and imprisonment." <br />/o-21-YS <br />Signature of Pemrit Applicant <br />Date Signed <br />Steven G. Renner 7rn~anr htn..~Eet <br />Name (printed) Title <br />b) Heavy Industry: the permittee shall also submit a copy of the SWMP to the Division with the permit application. <br />SWMP enclosed? ^ No ^ Yes <br />9. Signature of Applicant (legally 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 aU attachments 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 />sigztiflr-~nalties for submitting false information, including the possibility of fine and imprisorment." <br />B <br />Signature of Permit Applicant <br />David L. Bucknam Program Supervisor <br />Name (printed) Title <br />