Laserfiche WebLink
11/16/1994 15:25 3©3~2-039D CDH IJQCD W~ PAGE ©5 <br />4. Standjrd Indwtrial Clawitatlon (SIC) Code(i) for thin facility. (h-clude up a four, in order of impoctanceJ <br /> <br />S. Reoel~ing Stream: 'Ihe name of ffie receiving stream(s). (If discharge L to a ditch or storm sewer, also include the <br />name f the ultimate receiving water.) .(~ a K o 1 a ,-., r e e k h 1 .~ - 5' c e n:R k <br />6. <br />the Industrial adlvldes which tab place on dte. ~~ C .•, ~, ~ -~ ," ~ ~ ~ ~ I a a ,~ ,' <br />Bnvirotweafal Permits: Doat tbV facllhy arrrmtly have any eaviromamtal permits, or fs It subject to <br />under wither of the following programs? <br />a) <br />b) <br />Dischuge Permit System (COPS or NPDBS) <br />Mined Land Reclamuioo Bond <br /> <br />FY !/O I! [ ~ 'FO r ~ <br />n,a+ yY+ ;ssurd <br />8. <br />A <br />If , include MLRB permit anniversary date U u k N.e w ,n u H ~ ~ l <br />j r,n i+ issu rd <br />D ATIBR MANAGSMI3'!H'P PLAN ~ , A < I y ~4 H ,ru ~ r <br />twater Management Plan (SWMP) rhalf 6s prrpand prior ro aPpflosdoa for coverage under a general <br />and the following cerdflradoa sigmd. Sa the SWMP requiremeata k Appaodix A. <br />'I «tdt~ under penalty of lsw that a complete 5rormwster Management Plan, is compliance whh Appeodhr A of <br />th application, bas hem prepared for my facility. Based on my bttpriry of the person or parsons who manage <br />th system, or those pandas directly respotuible for gathering the informatbn, the SWMP k, to the beat of my <br />wledge and belief, true, atxatrate, sad complete. I am aware that there aro signiflcaat petultfa for falsely <br />c 'fyirtg the completion of said SWMP, including the possibility of fine sod imprisonment.' <br />of <br />9. Signtt~ure of Appliant pegally wponibk person) <br />Date <br />us <br />TINe <br />'I fy under petulty of law that I have personally examined cod am familiar with the information submitted in <br />this Ucatlon and all atrarhme~ sad that, based on my inquiry of those Iadivlduslc immediately reeponst3le for <br />ob the information, I believe that the information is true, accurate and complde. I am aware that there are <br />slgni cant penalties for submitting false infarmatlon, including the poseibilky of fine and imprisonment.' <br />of <br />Date <br />T'ltle <br />~! <br />.( <br /> <br />