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COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT May 21, 2001 <br />Water Quality Control Division <br />WQCD-P-B2 <br />4300 Cherry Creek Drive South <br />Denver, CO 80246-1530 <br />METAL MINING STORIVIWATER DISCHARGE PERMIT <br />REAPPLICATION & RECORD VERIFICATION FORM <br />This form is for reapplication for the Coal Basin Reclaim. Cons. Projects facility (COR-040204) under the stormwater general <br />permit for Metal Mining Operations and Mine-Waste Remediation. By filling out and signing this form and returning it to the <br />address at the top, you will have reapplied. in order to reapply by this simplified method, and to avoid a gap in coverage for your <br />facility, you must return this form by June 30, 2001. Do not send any money with this form -the billing process is handled <br />sepazately. <br />rvlore tmomtanon aoou[ ttus <br />me <br />This is the latest injormaiiox that we have in our records jor your facility. Please review the information carefully and make <br />whatever changes are necessary, by crossing out the incorrect information and writing in the new, and sign Iheform below <br />**RETAIN A COPY OF THIS FORM FOR YOUR RECORDS'* <br />Pennittee h~jor»~ation, including name of legally responsiblepersott who is signing rhisjorm: <br />Permittee - Colorado Div. of Miaerals 8a Geology <br />Federal Taxpayer ID Number - 84-0644739 <br />Legally Responsible Person - David L. Bucknam, Program Supervisor <br />Phone - 303/866-3567 <br />Mailing Address - 1313 Sherman Street, Rm 215 <br />Deaver, CO 80203- <br />Name, location and description ojindastrial activttyjor permitted facility: <br />Facility Name - Coal Basta Reclaim. Cons. Projects <br />Facility Address - End of Coal Creek Road <br />Redstone, CO 81623- <br />Facility County - Pitkia <br />Legal Location (Township, Range; Section) - T-10S, R-089W,S-11 SW <br />Latitude - 39/11)55 Longitude - 107/18/02 <br />Mine Status should be one ojthe following categories, "Alive, less than 10 acres", "Active, l0 acres or more'; or "Inactive mine". <br />Inactive mines are mixes that are no longer being actively mined Mines that are in temporary cessation are considered alive. Ijthe <br />status has changed from what is written below, please indicate which one ojthe three categories is appropriate jor the facility. <br />Mine ,Status - Active, less than 10 acres <br />Description of Industrial Activities -Earth moviag,stream channel reconstruction,topsoil <br />application, xevegetatioa. <br />Loco[ coital familiar with fhe s¢e: <br />Local Contact - <br />Local Contact Phone - <br />Stormwater Ducherges to: <br />Receiving Stream(s) <br />Stevea Renner, Project Manager <br />970/241-0336 <br />Dutch Creek tributary to Coal Creek <br />To complete this Reapplication, the Legally Respo¢sible Person named above must sign the following certscation: <br />I cert~ under penalty ojlaw that I have personally examined and am familiar with the information submitted on this form and that I <br />believe that the information is true, accurate and complete. Further, I understand that by completing and returning this form, l have <br />applied far coverage under the revised general permit jor StormwaterDischarges Associated with Metal Mining Operations andMine- <br />Waste Remedia[ion (COR-040000). <br />Signaturo of Legally Responsible Person Printed Name Date Signed <br />