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4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />a) 1442 b) c) d) <br />5. Receiving Stream: The name of [hP receiving stream(s). (If dischazge is to a ditch or storm sewer, also include the name of <br />the ultimate receiving waters.) South Pawnee Creek __ <br />6. Describe the industrial activities which take place on site. <br />Mine and stockpile pit run to be crushed on site <br />7. Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to regulation, <br />under either of the following programs? <br />No Yes Permit # <br />a) Colorado Discharge Permit System (CDPS or NPDES) X _ Aunlied for <br />X Applied for <br />b) Colorado Mined Land Reclamation Boazd _ _ <br />If Yes, include MLRB permit anniversary date <br />8. STORMWATER MANAGEMENT PLAN ~ <br />A Stonnwater Management Plan (SWMP) shall be prepared prior to appiicafioa for coverage under a general permit, and [he <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 prepazed for my facility. Based on my inquiry of the person or persons who manage the system, or <br />[hose persons directly responsible for gathering the information, the SWMP is, to the best of my knowledge and belief, true, <br />accurate, and com lete. I am aware that there are significant penalties for falsely certifying the completion of said S WMP, <br />including the pbility of fine and imprfsonment" <br />Applicant <br />Name <br />9. Signature of Applicant (legally responsible person) <br />Sor <br />"I certify under penalty of law that I have personally examined and am fami]iaz with the infomtation 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 information is true, accurate and complete. I am aware that there are significant penalties for submitting false <br />information, ' cluding the possibility of fine and imprisonment." <br />Signature of ~ennit Applicant Date Signed <br />Name <br />7/93/sg <br />-2- <br />Date Signed <br />Title <br />