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11/16/1994 15:25 303-0390 CPH WOCD Wl~ PAGE 05 <br />~ 4. Standard Indwtrlal Classiflatlon (SIC) Code(s) for this facllity. (include up to four, in order of importance.) <br /> <br />S. Reod~{na Strewn: "!fie same of the receivioS stream(s). (If diaciiarae h to a ditch or storm new1e1r, also include the <br />11ame f the ultimate recelvittg waters.) ...~d ~~ K o i ~ .i C. r r e ~,,, ~~ 1 d S C e rvt q G <br />6. Dasv~be fire Indtatrial adlrltla tvhleh Take play on die. ~~ c ,- 1~ ~ -~. ," ~, , ~ I o ~ ,~ , .., ~ _ <br />7. Oflter~ Bntlrontnental I'et~ila: Does thin facilky aurmtly have say emdmameatal petmia, or fa it attbJea to <br />wader either of the following programa7 <br />a) orado Discharge Permit System (COPS or NPDP.S) .r. <br />b) ]orado Mined Lead Reclamation Boatel _ ~ A.(Z? I r e d ~'a ~ . <br />If , include MLRB permit anniversary date U u k r,.e w N u u ~ ~ ( no + Y ` f ''sue ~ <br />pp1Yr,tl} ISSUY~ <br />g. STO ATSR MANAGSdffiMf PLAN L ~. ~ ~ /r ~~ H yu' Y ~ <br />A Sto water ManegemeM Plan (SWMP) shall bs prirppned p-forW appNNoaafon for coveraSe user a geaerd <br />permt noel the following eertifleadoa signed. See the SWMP requiremeaa is Appendix A. <br />d) <br />:erdt)r cadet penalty of law that a complete Stormwater Management Plan, In oompliaace whh AppeodGc A of <br />application, has been prepared for my facility. Based on my iagttiry of the person or persona who manage <br />system, of there panoN directly reapooalble for gathering the latormadon, the SWMP ia, Oo the hart of mY <br />wledge and belief, true, accurate, noel complete. I am aware thrt there aro aignititant pendtka fot falsely <br />afying the ootaplotion of raid SWMP, including the poraibility of fine noel impriaonmetd.' <br />of <br />Date <br />Title <br /> <br />9.6ipoa}tue of Applicant (legally twpotulbk person) <br />'i fy under penalty of law that 1 have personally examined and am familiar with the information submitted in <br />this Iftation and all attarbmenta sad that, based oo my inquiry of those individualc immediately reapomible for <br />ob the information, I believe that the inforation is true, aeeutue sad complete. I am aware that there ere <br />signs cant penalties for submitting false information, including the poasiblllty of flee sad ltnptlsonmwt.' <br />Date <br />99 <br />~. 1 <br /> <br />