Laserfiche WebLink
FOR AGENCY USE ONLY <br />PROCESS WATER AND STORMWATER <br />DISCHARGES ASSOCIATED WITH <br />C O <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC MIlVERALS <br />EXCEPT FCJEL) <br />YEAR <br />TYPE: <br />PERMIT NUMBER <br />DATE RECEIVED <br />MONTH DAY <br />P S <br />Please print or type. Do not a+ttempt.to complete this form before reading the instructions. <br />New G or Renewal V If renewal, existing permit number: co <br />1. Name and address of permit applicant: <br />Company Name: ~"t't.~,eeK .~yMPJt (1nryt,p/~11 u <br />Federal Taxpayer (or Employer) ID#: _, ,_ _ _ _ _ _ _ _ <br />Mailing Address : ~ ~, ~/~_~ttp~( ~1-y~J `~ /+ <br />City, State andZi~p~Cgode : w10Q•A~T' JDrt~RU S CO X33 <br />Phone Number : ITt t ) ~ ~~Od <br />Local Contact (familiar with facilityk ~P~ kl~A-i G Title: <br />Phone Numbers ) ~'l ~ ~ 00 Fax No.:~ ) <br />Who is applying for the permit? V Owner V Operator <br />2. Name and address of property owner: <br />Name: SW ChRm H~~S ~ -t 4~,, G <br />Mailing Address : sJ' ~~ ~~~ ~~nGI~C_A, p~,~ ~ .ice, ~J~~ <br />City, State and Zip Code : ~~gtcW t7c~cJ ~ W~~ 0 <br />PhoneNumber:(~J~) ~~ 1~0 FaxNo.: (~~ ) ~J3~ ~d <br />3. Location of the facility: <br />Street Address: r111G~ 2'~ ~ ~~ 20 1(~ <br />City, State and Zip Code: ~~ l ~AP~n- } lAtbe~-u~ <br />County: ~~~ Name of facility: ~-i~ ~t~ <br />Legal Location (Township, Range, section, 1/4 section): ~~ r SE ~; 9 ~~Z- eT NE t'~2(J ~R 1.'~-W bt" ~ N1 <br />Latitude and Longitude: '~ o~b ~ )~ ~ ~ , (b 4°Ljo •3'~'~ t <br />3 <br />