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P.ROCE;SS WATER AND STORMWA"1'ER <br />DISCIIARG.ES ASSOCIATED WIT>fI C O <br />SAND AND GRAVEL PROllUCTION <br />OPERATIONS (AND OTFIF,R <br />PtONMETALLIC MiNERAL5 <br />EXCEPT FUEL) <br />YEAR <br />TYPE: <br />FOR AGENCY USE ONLY <br />PERMIT NUMBER <br />DATF, RECEIVED <br />MONTH ~ DAY <br />Please print/o+r type. Do not adtempt to complete this form before reading the inshuctions. <br />New G or Renewal ~) if renewal, existing permit number: CO <br />I. Name and address of permit applicant: <br />Company Name: ~i~fr~R ~,,~ (~~Mpt}nU <br />Federal Taxpayer (or Employer) ID#: _ _ _ _ _ _ _ , <br />Mailing Address : ~~ Q, ~30~( °~-E~j !'~ <br />City, State and Zip Code : ~tpt?.~~ 4jDt~tytU S C~ 833 <br />Phone Number :~ ~a{ ~ ~OC~ <br />Local Contact (familiar with facility):~('~ kRth-i G Title: <br />Phone Number: (~`~ ) 5~i $ j ~Q Fax No.:1 1 <br />Who is applying for the permit? V Owner G Operator <br />2. Name and address of property~,owner. <br />Name: SW ChflM +l~~S L~~ <br />Mailing Address : ~~~~ ~~~ ~G'~t\. '+'W ~ ~, ~`~ <br />City, State and Zip Code : ~~gtC.Wde~e~ ~ W~~O <br />Phone Number:( ~~) ~3~ ~~O FaxNo.: {~~ ) ~~~ 6~~'C)() <br />3. Location of the facility: <br />i <br />Street Address:~~ 2'~ ~ ~~ 2l7 4 (e{, ,, f,,, <br />City, State and Zip Code:_ ~~ LIA~~ ~ ~ ~~ de~c~o <br />County: ~!~ Name of facility: ~l"t~ ~i~ <br />Legal Location (Township;. Range, section, 1/4 section):_ lJW ~ 5~ 4 ~ ~~~Z ~!' N~ ~ 1 2~ ` h ~~'W b~~ I +'~l <br />Latitude and Longinide:;~ c~b , y~ ~ N F I b 4°~p ,~34~ ~ <br />