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OR AGENCY USE ONLY <br />PROCESS WATER AND STOR'~IWATER PERMIT N[IMBER <br />DISCHARGES ASSOCIATED WITH C O - <br />Se+uYD AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER DATE RECEIVED <br />NONMETALLIC ~IINERII.S <br />EYCEPT FCEL) <br />YEAR ~ MONTH ~ DAY <br />TYPE: P S <br />Please print or type. Do not attempt to complete this form before reading the instructions <br />New ® or Renewal ^ If renewal, existing perms[ number: CO <br />1. Name and address of permit applicant: <br />Company Name: Lafarge West, Inc. <br />Federal Taxpayer (or Employer) IDN: 25-L531295 <br />Mailing Address :1590 W. 12i° Avenue <br />Ciry, State and Zip Code : Denver, CO 80204 <br />Phone Numcer : (303) 657-3000 <br />Lora! Contac[ (familiar with facility): Phillip Courtney Title: Environmental En ineer <br />Phone Numher: (303) 657ji118 Fax No.: (303) 657-4339 <br />Who is applying for the permit? ^Owner ®Opera[or <br />2. <br />Phone Number : (303) 657-4000 Fax No.: (3031 657-1339 <br />3. Location of the facility: <br />Street Address: County Road 20 'h <br />Ciry, State and Zip Code: Longmon[. CO <br />County: Weld Name of facility: Duckworth Pic <br />Legal Location (Township, Range, section, t/4 section): NE '/.. S 16. R68W. T2N <br />Latitude and Longitude: <br />4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importattce. See Appendix A.) <br />a) fat: b) c) d) <br />Name and address of property owner: <br />Name: C10 Lafarge West, Inc. <br />Mailing Address :1590 W. l2'" Avenue <br />Ciry, Stale and Zip Code : Denver, CO 80204 <br />5. Receiving Stream: The name of [he receiving stream(s). (If discharge is to a ditch or srorm sewer, also include the name of the ultimate <br />receiving waters.) Idaho Creek 3c Liehthousc ~~,~r '^rhiatt !akel <br />