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GENERAL PERMIT APPLICATION For Agency Use Only- <br />C•rfNrk4 'sF 4 F`f`?D ?t ^TS a 411J---r0 <br />V 1 --1 Wlk •T L x Lsf?. utJ..l 1L'?l\U LJ <br />ASSOCIATED WITH C O R - 5 4 <br />SAND AND GRAVEL PRODUCTION <br />vP RA 17 A%-VNS (AN'T"' V 1 ?11 L1\ Late Rcunvud <br />NONMETALLIC MINERALS Year Month Dav <br />EXCEPT FUEL) _- <br />, w a.. vv-.wvvn.J <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />1. 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 />V No Yes Product wash waters <br />t <br />No • Yes Maintenance/equipment wash waters <br />No Yes Transport waters (e.g., slurries) <br />U No Yes Scrubber waters (crushers or classifiers) <br />No Yes Mine dewatering (groundwater and/or runoff from the mine) <br />If you answered Yes to any of these questions, do not complete this application. You must instead complete the Process <br />• S^,. ,3+:n .,;r• y 'riXjtC'i.3 u:3:lwUl:; 1:.,,.. <br />Water ,z4,?'r ..?_m ;;' te;• ?i c rge .s .>ur.?wd..;-u•e.,.d Sand '. s$ G4' "'e3 atpliiCuti <br />_. <br />the Division. <br />2. Name and address ¦off permit applicant:? <br />.. 1w <br />Company ... Name: X1.11 J... ? ?\ <br />Federal. Taxpayer (or Employer) IDS- Z 3. J_ _ <br />Mailing Address: t : () . <br />\.lt y, otai lttiC: YtilU Llip Codc: j .' s??? i? t?rl ti i' <br />"I <br />- <br />Phone Number: (76 } j -,16 Who is applying for the permit Owner Operator <br />Local Contactt{??(ffa?amiliaar with facility): aW/,-, /U"TF- <br />vw iiuim,uer.-. <br />I ar-0io ' of tt$ facifit <br />Street Address: 1 ll ES _ 1?FF2i? C_ I AJCEC 0l <br />City, State and Zip Code: <br />County: Rj6C_ Name of facility: <br />Legal Location (Towns?hipp, Range, section, 1/4 sectioj9n): can ?8 1 ? ??? <br />r J <br />L aliiuac ailil LVtig'11ULLC€/ . i 1 D 0 1 0 -5 <br />i ytJ%-. Vl t al.tilty. 1Y GVC' iUGp11IrIIlt}J) ll?e"[`A1tVt1J i1ftGt YU7 t/7L) t?XiSiltt 45171 tV/1l7L) <br />7/93/sg - I -