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0 <br /> 4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br /> a) /y zO b) /Yz,2 c) d) <br /> 5. Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the <br /> name of the ultimate receiving waters.) r/��✓gR10 C/tccK . -SPi&V6 Cizeel< <br /> 6. Describe the industrial activities which take place on site. �/yIGyQG C2�S l// l/G �1/✓l� SCRcE viN� <br /> G/= L//Ylc SrOif/c C,J.4STc .-`c2 /�G,t'r�GSE Gr TCGq� /l1gTc2/�'c <br /> 7. Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to <br /> regulation, under either of the following programs? <br /> No Yes Permit A <br /> a). Colorado Discharge Permit System (CDPS or NPDES) d _ <br /> b) Colorado Mined Land Reclamation Board �[ <br /> If Y, include MLRB permit anniversary date <br /> 8. STORMWATER MANAGEMENT PLAN <br /> A Stormwater Management Plan (SWMP) shaU be prepared prior to application for coverage under a general <br /> permit, and the following certification signed. See the SWMP requirements in Appendix A. <br /> 'I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of <br /> the application, has been prepared for my facility. Based on my inquiry of the person or persons who manage <br /> the system, or those persons directly responsible for gathering the information, the SWMP is, to the best of my <br /> knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for falsely <br /> certifying the completion of said SWMP, including the possibility of fine and imprisonment.' <br /> f <br /> Signature of Permit Applicant Date Signed <br /> Name (printed) Title <br /> 9. Signature of Applicant (legally responsible person) <br /> 'I certify under penalty of law that I have personally examined and am familiar with the information submitted in <br /> this application and all attachments and that, based on my inquiry of those individuals immediately responsible for <br /> obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are <br /> significant penalties for submitting false information, including the possibility of fine and imprisonment.' <br /> Signature of Permit Applicant Date Signed <br /> Name (printed) Title <br /> 7/93/sg -2- <br />