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4 Standard Industrial Classification (SIC) Code(s) for this facility (Include up to four, in order of importance.) <br />a) 1411 b) c) d) <br />i Receiving Stream: The name of the receiving stream(s) (If discharge is to a ditch or storm sewer, also include the name of <br />the ultimate receiving waters) North Clear Creek <br />b Describe the industrial activities which take place on site. <br />Blasting, excavation and crushing of construction aggregates. <br />7 Other Environmental Permits Does this faahty currently have any environmental permits, or is rt subiect to regulation. <br />under either of the following programs? <br />a) Colorado Discharge Permit System (CDPS or NPDES) <br />b) Colorado Mined Land Reclamation Board Currently under <br />If Yes, include MLRB permit anniversary date application <br />8 STORMWATER MANAGEMENT PLAN <br />~. M-2004-067 <br />A Stormwater Management Plan (S\VMP) steal! be prepared prior to application for coverage under a general permit, and the <br />following certification signed. See the SWMP requirements in Appendix A <br />"I certify cinder penalty'of law that a complete Stormwater Management Plan, in compliance with Appendix A of the <br />application. has been prepared for my facility. $ased on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible for gathenng the information, the SWMP is, to the best of my knowledge and belief, true, <br />accurate, and complete I am aware that there are significant penalties for falsely certifying the completion of said SWMP, <br />including the ptisstbihty ofline and imprisonment." <br />/~i <br />Signature of Permit Applicant <br />-7 i (.: - <br />J <br />Signed <br />Robert Lembke Manager <br />Name (panted) Title <br />9 Signature of Applicant (legally responsible person) <br />"2 certify under penalty of law chat 1 have personally examined and am familiar wish the m(ormation submitted in this application <br />and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, 1 <br />behetie~that the inform anon is [rue, accurate and complete, 1 am aware that there are significant penalties for submitting false <br />i' i~ <br />iinformation, including the possib liiy of fne and impnsonment " <br />-,'/, / / <br />---~ , i ~ ~ - - t I J (l ~i' <br />Signature of Permit Applicant Date Signed <br />Robert Lembke Manaqer <br />Name (panted) Title <br />~;ow~ -2- <br />