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4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance-) <br />a) I ,44 Z- b) C) d) <br />5. Receiving Stream: The name of the recteiving stream(s). (If discharge is to a ditch or storm sewer, also include the name of <br />the ultimate receiving waters.) zvlwe ,(-_}-LL ?jIzev11 Wk--`-K Camt/ op <br />to IV S Tom' <br />6 <br />7. Other <br />a) Colorado Discharge Permit System (CDPS or NPDES) <br />b) Colorado Mined Land Reclamation Board <br />under either of the following programs? <br />If Yes, include MLRB permit anniversary date <br />8. STORMWATER MANAGEMENT PLAN <br />_A14 <br />No Yes Permit # <br />- X M -??sf _ per = <br />A Stormwater Management Plan (SWMP) shall be prepared prior to application for coverage under a general permit, and the <br />following certification signed. See the SWMP requirements in Appendix A. <br />"I certify under penalty of law that a complete Stormwater Management Plan, in compliance with Appendix A of 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 for gathering the information, the SWMP is, to the best of my knowledge and belief, true, <br />accurate, and complete- I am aware that there are significant penalties for falsely certifying the completion of said SW-MP., <br />including the possibility of fine and imprisonment." <br />Signature of Permit Applicant <br />Name (printed) <br />9. Signature of Applicant (legally responsible person) <br />Date Signed <br /> <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application <br />and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, 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 />& <br />Signature of.Permit Applicant Date Signed <br />Name (printed) <br />7/93/sg <br />-2- <br />Title <br />Environmental Permits: Does this facility currently have any environmental permits, or is it subject to regulation,