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<br />PROCESS WATER AND STORMWATER ~_ <br />DISCHARGES ASSOCIATED WITH ~ O <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC 1VIINERALS <br />ERCEPT FUEL) <br />YEAR <br />TYPE: <br />FOR AGENCY USE ONLY <br />PERMTT NUMBER <br />DATE RECEn'ED <br />MONTH DAY <br />Please print ar type. Do not attempt to complete this form before reading the instructions. <br />New ®or Renewal ^ If renewal, existing permit number: CO <br />Name and address of permit applicant: <br />Company Name: u!~ITtQ Cflrt~.Ph-nil~S <br />Federal Taxpayer (or Employer) ID#: ~ ~ _ ~ ~ ~ QS 3 (~ <br />Mailing Address: eC.CZ3 RILI ~'R RDftD 1 Q dOx r-G0~{ <br />City, State and Zip Code : ~j,~}n}~ ~j ~(JC'I'(p /.I t?QLOf2R.f~i7 g j5'p~ _ <br />Phone Number : (97n 1 .2// 3 y 9/~~0 e ^ <br />Local Contact (familiar with facility): t7f~ 8Rli-Ey Title RILE 1}RF4~ /LL4N,4r,~ <br />Phone Number (47n 1 G,2S 37.?R' Fax No.: (47n 1 !a1.5 5s^L>`5 <br />V/ho is applying far the permit? ^ Owner ©Operator <br />2. Name and address of property owner <br />Name: ~X E(-.~C~QQ ~p 1p-~~1 O tJFJ ~ficp ~y <br />Mailing Address: ~~QQ` n.Oll=i~5 <br />City, State and Zip Code : /VIEEKEE C~ 8 i6'~ ~ <br />Phone Number : (~~~ 1 S 7~ ~/ 02~ Fax No.: ( - 1 -" <br />3. Location of the facility: <br />Street Address: ~ ~ Q~ R ~ #'J <br />City, State and Zip Code: f~KC"'~` <br />$i(c4 <br />County: Rl0 6~+/,rc Name of facility: PI~'ERrJG~ P,-~ <br />Lcgal Location (Township, Range, section, I/4 section): I j ~ R a~ ~ ~cTjptJ a Nu! 1/-f <br />Latitude and Longitude: ~~°05 /.24.5 '~J~ ~Qc4~/y'Sy, (,j t`W <br />