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Colorado Department of Public Health & Environment FOR AGENCY USE ONLY <br />Water Quality Control Division <br />WQCD-P-B2 REC <br />4300 Cherry Creek Drive South EFF <br />Denver, Colorado 80246-1530 YEAR MONTH DAY <br />INACTIVATION NOTICE FOR <br />MINING STOWMWATER DISCHARGE GENERAL PERMT CERTIFICATION <br />Please print or type. Form must be filled out completer <br />Certification Number: COR-04 Taxpayer ID or EIN <br />--OR- COG-50 <br />Pennittee (Company) Name: <br />Pennittee Address: <br />Mine/Facility Name: <br />Mining Site Address/Location: <br />County: Contact Person: <br />Reason/justification for inactivation, and description of final site stabilization. (Attach any supporting documentation, <br />such as proof of Mined Land Reclamation Board bond release): <br />I certify under penalty of law that by the date of my signature below, all disturbed soils at the identified mining site have <br />been finally stabilized; all temporary erosion and sediment control measures have been removed; all mining and <br />equipment maintenance waste have been disposed of properly; and all elements of the Stormwater Management Plan <br />have been completed. <br />I understand that by submitting this notice of inactivation, I am no longer authorized to discharge ston°nwater associated <br />with mining activity by the general permit. I understand that discharging pollutants in stormwater associated with <br />mining activities to the waters of the State of Colorado, where such discharges are not authorized by a CDPS permit, is <br />unlawful under the Colorado Water Quality Control Act and the Clean Water Act. <br />I certify under penalty of law that I have personally examined and am familiar with the information submitted herein, <br />and based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the <br />information is true, accurate and complete. I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonment. (See 18 U.S.C 1001 and 33 U.S.C. 1319.) <br />Signature of Permit Applicant (Legally Responsible Party) Date Signed <br />9/97/mn/inme (pFinted) i e