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<br /> <br />GT=~.RAT PEt??~fl_?' APPLICATION <br />STORMWATFA DISCI~iARC3ES <br />ASSOCIATED WPTH <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTffiR <br />NONMETALLIC MINERALS <br />ERCEPT T'VEL) <br />~~ <br />FOR AdSNI:Y USfi ONLY <br />C~tifiratiar Number <br />C O G- S O <br />Date Received Fae <br />Year Mauth Dray <br />(Fermat No. COG•500000) <br />Please print or type. Do not attempt to complete th4 form beface reading the iastznabns. <br />I . Is th4 the enereex rppGtaatioo tar yotr tadGtyTi Thb applicadon is only for the discharge of s wrier. <br />~e~eiv~ <br />Do you diachar=e any of the following ptvcsas `orated wattewatan from your facilhyrt <br />No ^ Yes Product wash water APR ~ `~ ?001 <br />No ^ Yea MaintmaacdeQuipmem waa6 waters Olvision a Moe a sd& Geo <br />No ^ Ya Tramport watso (e.g., shmies) o9Y <br />No ^ Yes Scrubby waters (auahee or classiflsra) <br />No ^ Yes Mine dewateeiog (gottrdwater and/or raaof'f from the mine) <br />If you answered ]'m to say of these questions, do rot complete thin application. You moat instead complete ffie <br />Process water sad Stortnwster Dlschtr=es Assodated with Srad and tan~d application for this fsciltry, which is <br />available from the Division. <br />2. Name and address of permit applicant: <br />Company Name: ~ ~' ~ =~ rDiU t Cn Y/VLt - <br />Federal Taxpayer (or I.mpbry~er) IDr: ~ ~, ~. ~ ~, .L .Z 12 ~,. <br />Mailing Address: ~ D • te]nX / /o',.Z. <br />Ciry, State and Zip Code:~nu e. t"_r .~ ~ (t f> - ~ I ~ ask <br />Phons Number: (mil ~ D I G.7 7 - ~ 7 /~,_ 1 ''a applyit~ for the permiC! ~ Owner ^ Operator <br />Local Contact ( iar with faciliry):.~~ P_'~ e1.JP~~ <br />Title:,~eA_r~e.h r ~ ~r:C' f: rr,~ p Phone Number: (~ 7 G ) l0 7 7 -~-1 15.Q <br />3. i.oratlan of the hdllq: II <br />Street Addreee: w ~--, } S, a r>. Ct~ P d ~ 8 4' <br />Ciry, State and Zip Code: u" Z~ <br />County: ;~) -'19~=.. ~ Name of facility: ` <br />Legal Location (Township, Ranee. sexxioa, 1/4 section): ~; e ~ °C ~ ~ I:N .~17 T. <br />