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GENERAL PEEMMAPFLIC 10N <br />vii van?i* i ?? ii TER DISCHARGES <br />ASSOCIATED WITH <br />SANDD AND GRAVEL PRODUCTION <br />O i?Li\t! T iVINS k<3ND O jRER <br />NONMETALLIC MINERALS <br />For Aeencv Use Only <br />COR-40 <br />Date Received <br />V-ar A4--.t, Tx- <br />12 <br />EXCEPT FUEL) <br />(A_ ,+t Xi- 00G civnnnni <br />vVVV) <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />I . 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 />hio a Yes Product wash waters <br />No a Yes Mai itenanctlequipment wash waters <br />No a Yes Transport waters (e.g., slurries) <br />No ° Yes Scrubber waters (crushers or classifiers) <br />No III Yes Mine dewatering (groundwater and/or runoff from the mine) <br />If you -answered Yes to any of these questions, do not compieie this application. You must instead complete the Process <br />Water and Storm-water Il:e hw-ftrue d??,,cztted __a,16o.... __.. ?.---- <br />:sw •_ •-•. w.w .waved and Craver application for this facility, wtuch is available from <br />the Division. <br />2. Name and address of permit appikaw: <br />ottt:,y :.await . tJ !/1TIViJ LP- / Vf/ <br />1D#: Z D Q .L 4 B o l l g Co• SFC ST,?r fit) -.46C <br />??IAW k_4 <br />Mailing Addrm: all <br />City, State anrll 7tp CAP. A P A J e- A 6Yl / <br />Phone Number: (!?2p ) 82-1 -4767 Who is applying for the perm Owne o Operator <br />Local Contact (familiar with fa6hty): K. 5:0 TT- 13,KCN 15 E Title: /1711/e-9 Phone A umber. 921 1 <br />. Location of the facility: , <br />Street Address: 4j <br />Count3': Name of facility: _ fl / ??l/ 1 +?a k'? A'' ? 'T' <br />Legal Location (Townshi Range, section, 114 sesstost): . ?? <br />Latitude'and LonPhxdpN L.t>yi•! _ ° 2n 4!G ' _ . ? , / .-se <br />Type of Facil ew lheflirnino nr,errt;n?o • F. Intl I • <br />J a a r , V, _„?j Exisiiug (as of 10/ i/Y2) <br />?/93/sg <br />-r-