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4. Standard Industrial Classification (SIlC)dC~o}de(s) for this facility. (Include up to four, in order of importance.) <br />a) f ~'2~ b) f 1" !'7' c) d) <br />5. Receiving Stream: The name of the receiving streams}. (If dishazge is to a ditch or storm sewer, also include the name of <br />the nlrimate receiving waters.) <br />6. Describe the industrial activities which take place on site. <br /> <br />7. Other Enviroamenta)'Permits: Does this facility currently have any environmental permits, or is it subject to regulation, <br />under either of the following programs? <br />a) Colorado Discharge Permit System (CDPS or NPDES) D(ICUtrxt S <br />b) Colorado Miced Land Reclamation Board F rvu-1Lt~~ <br />If Yes, include MLRB permit anniversary date <br />3. STORMWA'I'F9t MANA(~ffigT PLAN <br />Yes Permit # <br />5~ - - <br />A Stormwater Management Plan (SWMP) shat( be prepared prior ro apptication for coverage under a general permit, and the <br />following certification signed. See the SWMP requirements in Appendix A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of the <br />application, has been prepared for my facility. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathering the information, the SWMP is, to the best of my ]mowledge and belief, true, <br />accurate, and complete. I am aware that there are signifcam penalties for falsely certifying the completion of said SWMP, <br />including J,>pe possibility of~ne and <br />6-~-0~ <br />Date Signed <br />!//~ <br />Name Turin <br />9. Signature of Applicant (legally responsible person) <br />"I certify under penalty of law that I have personally eiam;ned and am familiar with the information submitted in this application <br />and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I <br />believe that the infomration is tme, accurate and complete. I am aware that there are significant penaltes for submitting false <br />information, including the possibility of fine and imprisonment." <br />1 I - 0'1 <br />Permit Applicant <br />Name (printed) <br />7!93!sg <br />-z- <br />Date Signed <br />Title <br /> <br />~ec.._ , <br />