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GENERAL PERMIT APPLICATION <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH <br />METAL MINING (Permit No. COR-040000) (and <br />some Coal Mining -see Instructions) <br />For Agency Use Only C O R- 0 4 <br />Date Received: _ _ / _ _ / _ _ _ <br />Month Day Year <br />ALL APPLICANTS MUST FOLLOW THE DIRECTIONS FOR COMPLETION OF THIS FORM IN <br />PART C OF THE INSTRUCTIONS <br />Please print or type. All items must be completed accurately and in their entirety or the application will be deemed incomplete <br />and the application returned. Processing of the application will not begin until all information is received. Please refer to the <br />instructions for information about the required items. Original signatures for Items 7 and 8 are required. <br />1. Name and address of the permit applicant: <br />Company Name Bluerock Energy Corp. <br />Mailing Address 36 west Main street <br />City, State and Zip Code Cortez, Colorado 813x1 <br />2. <br />Phone Number (970 ~ s6s-lzza <br />Local Contact (familiar with facility) Tim Pierce <br />Title Environmental Manager Phone Number (970 ) 864-71s2 <br />Local Contact E-mail Address tpierce@bluerockresources .com <br />Legally Responsible Person (application signer) E-mail Address tpierceQbluerockresources .com <br />Location of the Facility: <br />Street Address rr/A <br />City, State, and Zip Code Located - 4.6 mi SW of Paradox, CO & 7.8 mi west of Bedrock, CO <br />COUnty Montrose Name of Facility J-Birds Mine <br />Latitude/Longitude -use one of the following formats: <br />Latitude 38 / 19 / 42 Longitude 109 _ / of / s6_ (e.g.,39°42'11", 104°55'57") <br />degrees minutes seconds degrees minutes seconds <br />-or- <br />Latitude _ _ . _ _ _ Longitude _ _ _ . _ _ _ (e.g., 39.703°, 104.933°') <br />degrees (to 3 decimal places) degrees (to 3 decimal places) <br />3. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to three, in order of importance.) <br />a) 1094 b) ~) <br />4. Permit Category: Under which mining category does this facility belong? (See Appendix A.) <br />Metal Mining X Coal <br />Mine Category: Which category is your facility under? <br />Active mine, less than 10 acres X Active mine, 10 acres or more Inactive mine <br />Colorado Division of Reclamation, Mining and Safety Permit Number (if applicable): M2 0 o s o s o <br />Who is applying? Owner X Operator <br />3/07/MM I of 2 <br />