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------ -- --- - -. W._ ~...~. <br />•. Staurdard Iladuetrial Ckudtlntlm ~[C) GieW for This facility. (Iocltsds up w tour, in order of impornnce.) <br />a} ~tL~n b) 1 L~I n c) J 1111 d) <br />S. lieoehfog Bteeam: The frame of the reca[vh~g <br />name of the ultimate receiving waters.) _1dLe <br />L m a ditch or swan sewer, alw Include the <br />6. Daaaibe the indttafeid aetldtles vahkh bb plena m aiq. / . L'L _ _ L /., ,, c: L,n n a k ~ ; ~- <br />7. tJtiter Fi~vlroomeotal Permits: Doss th4 tacilhy ~4 have any ettvirotuttemtal permits. or is 8 sub}ect m <br />regttltttion, under either of the ioliowigg ptogrsms? <br />a) Colorado D1acLarge Permit System (COPS or NPDES) <br />b} Colorado Mined Land Reclamstton Board <br />- <br />Yn Permit <br />m _~mn _ Intl <br />If ~'~, include MLRB petmk amiveesuy dais <br />8. STOjtMWAT'1>it MANAG~-t~TP PLAN <br />A Smtmwater Matutgemeat Plea (SWM~ rltal/ ikPnPtrndprtiorM appltenatos for coverage under a geaaal <br />permit. and the following certitlcatlon sigtwd. See the sWAip tegttiremmts in Appendiu A. <br />'I t:eetlf~ wader pmalty o[ Lw That a complete Swtmwtaer Maoegemeot Dian, In compliance with Appmdhr A of <br />the applicadon, has bem prepared tot my facility. Based on my inquiry of the perwn or persona who marrttge <br />the sysoem, a those persons directly reeponeibie !bc gaTbxh-g the tntbrmation, the SWMP is, m the best of my <br />iowwledge ttad belief, true, acaaate, tmd cor~lau. 1 am aware that TherO tae signiflcaot penalties for falsely <br />cmtifying the completion of raid SWMP, inclTding the ptapibility of tine std impriwtmttmt.' <br />Nams (vrided) ~ 17tle <br />9. Signature of Appllamt (kgaDy wpoaaibN ptssee) <br />'I certify user penalty of law that I Gave personally e:amined and am familiar whh the information submitted in <br />this applluaion noel all auachmmta sad that, based on my inquiry of those iodividuale immediately respomible for <br />obtaating the httormatioa, I bdiew that the information is true. arcurete and ooraplete. I am aware that there are <br />aigtritfcmt peodtla for twbmhting tylse information, incinding the possibility of Sne a~ imprisonmemt.' <br />SiynaOree <br />Date Sl;tbd <br />i~sr.a .2. <br />