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olorado Department of Public Health & Environment <br />Water Quality Control Division <br />WQCD-P-B2 <br />4300 Cherry Creek Drive South <br />Denver, Colorado 80246-1530 <br />FOR AGENCY USE ONLY <br />REC <br />EFF <br />YEAR MONTH DAY <br />INACTIVATION NOTICE FOR <br />MINING STORMWATER DISCHARGE GENERAL PERMTT CERTIFICATION <br />Please mint or twe. Form must be filled out comoletely. <br />Certification Number: COR-04 U ~ o <br />--OR-- COG50 <br />Taxpayer ID or EIN g ¢ ' 0 6 ¢ ¢ ~ 3 q <br />Pemuttee(Company)Name: Cy_[o2~i-do /7~wSru/ ~F Miw.e2.r/S ~- /reu/oL-y <br />Permittee Address: (3 /3 S/~G /Err.Y•v S % RctT 2 uorr ,~-/ S <br />~c~~c2~ c~l~R~dn sv}-o3 <br />MinelFacilityName: Guwl /3R5/w/ Re~GH/Y~+Y~nn/ CrtisTR~criuwi /~/2r~~ ~T l <br />Mining Site Address/Location: Ew.d u F G~/4L GR+c ft /1u.rd 4 /aii ~s w . uF /IGJSru.~.e <br />County: ~rKr.~ Contact Person: ST~~.t ~/ /Lew/.VG/Z <br />Reason/justification for inactivation, and description of fmal site stabilization. (Attach any supporting documentation, such <br />as proof of Mined Land Reclamation Boazd bond release): <br />ee <br />I certify under penalty of law that by the date of my signature below, all disturbed soils at the identified mining site Lave <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 discharge stormwater associated <br />with mining activity by the general pemtit. 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 hereut, and <br />based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information <br />is true, accurate and complete. I am awaze that there aze significant penalties for submitting false information, including the <br />possibility of e and impn~n/ment. (S~ 18 U..C 1001 and 33 U.S.C. 1319.) // / <br />(h.[A.l~ (A,,,G~~ 4 39 0 <br />Permit Applicant (Legally Responsible Party) Date Signed <br /> <br />