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ENERAL PERMIT APPLICATION <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH: <br />LIGHT INDUSTRIAL ACTIVITY <br />(Permit No. COR-010000) <br />HEAVY INDUSTRIAL ACTIVITY <br />(Permit No. COR-020000) <br />METAL MINING (Permit No. COR-040000) <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />1. Name and address of permit applicant: <br />Company Name: <br />Federal Taxpayer (or Employer) ID{i: <br />Mailing Address:- <br />City, State and Zip <br />Phone Number: ( ) Who is applying for the permit? <br />Local Contact (familiaz with facility): <br />Title: <br />2. Location of the facility: <br />Street Address: <br />City, State and Zip Code: <br />County: Name of facility: _ <br />Legal Location (Township, Range, section, 1/4 section): <br />Latitude and Longitude: <br />Type of Facility: ^ New (beginning operations after 10/1/92) ^ Existing (as of 10/1/92) <br />3. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />a) <br />b) <br />FOR AGENCY USE ONLY <br />Certification Number <br />C O R - 0 <br />Date Received Fee Category <br /> <br />Yeaz Month Day <br />c) <br />d) <br />4. Permit Category: Under which stormwater general permit does this facility belong? (See Appendix A.) <br />^ Heavy Industry ^ Light Industry ^ Metal Mining (or Coal -see Instructions) <br />Mines only: MLRB permit anniversary date Which category is your facility under? <br />^ Active mine, less than 10 acres ^ Active mine, 10 acres or more ^ Inactive mine <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). <br />P)lone Ntunber: ( ) <br />Owner ^ Operator <br />~isenhm -1- <br />