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<br />11/16/199: 15:25 30'2-0390 <br />I <br />5T0 ATER I)ISCIIAROES <br />ASS TED WfCH <br />SAND GRAVEL PRODUCTION <br />OPF•RA ON3 (AND OTHER <br />NO ALLIC MINERALS <br />EXC t?[JEL) <br />(Permit N .COO-500000) <br />FAGE Oa <br />II I II pOR AOHNCY USE ONLY <br />Cattifatioo Number <br />C O G- 1 0 <br />pate Realvad Pas <br />Year Monrh Day <br />Place at or qpe. Do not attempt to complete this form before reading the insrtuetiona. <br />t . is tits the twtrett appUatloo la your fitdUty77 lbis appllention is ody for the discharge of atortnwater. <br />Do yo~t diarbarge any of the toUowiog process generated waatevvaten Aram your 6cUity'} <br />~Io ^ Ya <br />. i~lo ^ Yes <br />~lo ^ Yes <br />o ^ Yee <br />o ^ Yes <br />Product wash water <br />Malntemnce/equlpment wash waters <br />Transport water: (e.g., alarries) <br />Scrubber water (graben ar claaslfiers) <br />Mine dewsterhtg (~oundwstec and/or rtmoff from the mine) <br />if you answered yyi to soy of these quatlona, do not complete this applleatfon. You mwt instead complete the <br />Water and t~ormwatar Dlaeharpa Ateodated with Said and Grad application for thla faeilitp, which is <br />avails le from the Division. <br />2. <br />cad address of permit appUtant: <br />iy Name: ...~~ ~ ~ • I \ r< s c c 1/ _ ~ ra y e 1 ~~ I <br />Taxpayer (or Employer) iDg: ~ ~ 3 ' Y (a = ~' 9 2 Sec , 4 / S ~ ~ ~"' <br />States sod Zip Cade: 1 ~ ~ ~ I l ~ a . !- D u~ L° t1 R C .S ~ 9 ~„ <br />s Ntunber: (3y3~ .'~(o ~ - ~.r.S/ Wbo u applying for the permit? ®Ownar ^ Operator <br />Contact (familiar with facility}: -~~ ~ <br />de: Phone Number: ( ) <br />3. <br />of the hdUq: <br />Address: <br />City State and Zip Code: ~ <br />Couyty: L 4 v ~' rrr ~ r Nams of facility: ~.fL' <br />Leg Location (Township, Range, section, l/4 seaion):.~~ <br />Lati~tde and Longitude: ~{ ~ ° ~/ .5 m ~ H /. ~ s e~ <br />Typd of Paclllty; ^ New (tregtnniug operatium after 10/1192) <br />7/93/.: <br />CDH WL~CD ~C <br />III IIIIIIIII II <br />sss <br />c. <br />0 <br />lbl Eafatlog (act oP 10!1/92) <br />