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GENERAL PERMIT APPLICATION FOR AGENCY USE ONLY <br /> STORMWATER DISCHARGES <br /> certification Number <br /> ASSOCIATED WITH <br /> SAND AND GRAVEL PRODUCTION C O G - 0 5 <br /> OPERATIONS (AND OTHER Dare Received Fee category <br /> NONMETALLIC NE NERAIS <br /> EXCEPT FUEL.) Year Month Day <br /> (Permit No. COG-500000) <br /> Please print or type. Do not attempt to complete this form before reading the instructions. <br /> 1. Is this the correct application for your facility?? This application is only for the discharge of stormwater. <br /> Do you discharge any of the following process generated wastewaters from your facility? <br /> ❑X No ❑ Yes Product wash waters <br /> © No ❑ Yes Maintenance/equipment wash waters <br /> * No ❑ Yes Transport waters (e.g., slurries) <br /> ❑x No ❑ Yes Scrubber waters (crushers or classifiers) <br /> © No ❑ Yes Mine dewatering (groundwater and/or runoff from the mine) <br /> If you answered YYes to any of these questions, do not complete this application. You must instead complete the <br /> Process Water and Stormwater Discharges Associated with Sand and Gravel application for this facility, which is <br /> available from the Division. <br /> 2. Name and address of permit applicant: <br /> Company Name: /262"0117— <br /> Federal Taxpayer (or Employer) lD#- Y 6 0 0 0 7 6 <br /> Mailing Address: 1215-A'11nAI cvyT`/ /e�iZT�/GaSE G/S /y/�4Co c/ Arc <br /> City, State and Zip Code: L'O rP/ Zi <br /> Phone Number: ( 7/ � ) Who is applying for the permit? ❑ Owner ❑ Operator <br /> Local Contact (familiar with facility): LCc-u/ 441, <br /> Title: (-3 c c'ui 61 S T Phone Number: ( 7/ /` ) %`/�— 5,/7 F <br /> 3. Location of the facility: <br /> Street Address: 3. / /{9/ccS WcST Oi= IW4,,ORU /]?- Cif,y i✓�p G0 .—�2&i'zY <br /> City, State and Zip Code: x4i6 -0/?<% CO P/,Z 33 <br /> County: Name of facility: ,(lGc✓giZ// <br /> Legal Location (Township, Range, section, 1/4 section): yE'V /OE 6 . L-7— <br /> Latitude and Longitude: <br /> Type of Facility: ® New (beginning operations after 10/1/92) ❑ Existing (as of 10/l/92) <br /> 7/93/sg -1- <br />