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a: ;Standard Industrial Classification (SIQ -Codv(s) for this fwflit,, <br />a) / 44- 2-- b) c). <br />d) <br />5. Receiving Stream: The name of the recieiving stream(s). (If discharge is to a ditch or storm sewer, also include the name of <br />(lie ultimate receiving waters.) L wz? ra-hW *xro <br />6. Describe the industrial activities which take place on site. <br />t -- - <br />S L?'i=iL' ?.. OL <br />7. Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to regulation, <br />under either of the following programs? <br />a'} Cc;luradu Disc talge Perim, S-ystern (CDPS or Nil?DES) <br />b) Colorado Mined Land Reclamation Board <br />If Yes, include MLRB permit anniversary date <br />S. STORMWATER MANAGFMENT PLAN <br />N/.f <br />No Y <br />OKI <br />X- M-1981- nor -?. <br />A Stormwater Management Plan (SWMP) shall be prepared prior to application for coverage under a general permit, and the <br />,htl w',.«g CvTtifi ion signed. Seethe CWN4P reg ircin nts in Appcndi <br />...: J <br />"I tcrtiN under .,;;,.,;t.' c,f 1. w that a complete, c.7;zrs Water it 2r,n r,:ettt Plan, in co ;pl is ce with i? ppRp nd;;; A o-f the.. <br />application, has been prepared for my facility. Based on my inquiry of the person or persons who manage the system, or <br />those persons directly responsible ;or gathering the information, the SWMP is, to the best of my knowledge and treltef, true; . <br />accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said SWMP, <br />including the possibility of fine and imprisonment." <br />3f.Cant <br />1 ,s <br />Name (printed) i <br />9. Signature of Applicant (legally responsible person) <br />il?1P alma ?? <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application <br />and ail BiiaCi+ae?c,Ti? anti uai, b aSed t:ii Wiy if;gU.ijy of -jhoaZ Tid1V,,iduAg iir"iediate,y TC asibie for (k)t'aining the in' ormailon, i <br />believe that the 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." <br />Signature of Permit Applicant Date Siened <br />(Include up to f 4 order of import _nce.+. <br />f <br />v? <br />l;i o Jr obi.; <br />/93/sr <br />-2-