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GENERAL PERMIT APPLICATION For AQencs! Use Only <br />STORMWATER DISCHARGES <br />ASSOCIATED WITH e o R -s o <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />Received <br />Year Received Day <br />NONMETALLIC MINERALS Date <br />EXCEPT FUEL) <br />Wcrmn No COG-500000) <br />Please print or type Do not attempt to complete this form before reading the instructions. <br />Is this the correct application for your facility?? This application is only for the discharge ofatorrnwaiter <br />Do you discharge any of the following process generated wastewaters from your facility') <br />No * Yes Product wash waters <br />No * Yes Maintenance/equipment wash waters <br />No 10 Yes Transport waters (e.g , slurries) <br />No Yes Scrubber waters (crushers or classifiers) <br />i <br />0 Yes Mine dewatering (groundwater and/or runoff from the mine) <br />I <br />If you answered Yes to any of these questions, do not complete this application. You must instead complete the Process <br />Water and Stormwater Discharges Associated with Sand and Gravel application for this facility, which is available from <br />the Division <br />Name and address of permit applicant- <br />Company Name- Clear Creek District Water Providers. LLC <br />fcderal Taxpayer (or Employer) im 2 0 1 4 9 9 3 9 9 <br />Mailing Address 5460 South Quebec St., Suite 110 <br />City. Siaic and Zip Code Greenwood Village, C080111 <br />Phone Number ( 303) 773-1005 Who is applying for the permit" a Owner " <br />Local Contact (familiar with facility) Robert Lembke <br />Title -Manager Phone Number.-( 303 ) 773-1005 <br />Location of the facility <br />Street Address -approx. 5 miles east/southeast of Black Hawk, along SH 119 <br />City, State and Zip Code- <br />County Gilpin Name of facility MMRR Quarry <br />Legal Location (Township. Range. section, 1/4 section) Township 3 South, Range 72 West, Section 26, NE 1 /4 <br />Latitude and Longitude 39 degress 45' 59" (N) 105 degrees 24'48"(w) <br />i <br />Type of Facility New { eginning operations after 10/1192) Existing (as of 10/t/92) <br />?•-1ksg <br />2666