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<br />• <br />PROCESS WATER AND STORMWATER <br />DISCHARGES ASSOCIATED WITH <br />C O <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC MINERALS <br />EXCEPT FUEL) <br />YEAR <br />FOR AGENCY USE ONLY <br />PERMIT NUMBER <br />1-1 I-T-T <br />DATE RECEIVED <br />MONTH DAY <br />TYPE: <br />is <br /> <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />New G or Renewal G If renewal, existing permit number: CO <br />Name and address of permit applicant: <br />Company Name: M A ?OtJGeET? C o&;-sT ye:rt o :J (iJ ?• <br />Federal Taxpayer (or Employer) ID#: Ell 0 9 0 7 A 9 1 <br />Mailing Address: 732S 41 VE R.. ROAD <br />City, State and Zip Code: 49A0 D JuWG.TwP-, elo SISOS" <br />Phone Number:.( 470 1 g43 3Z2 t <br />Local Contact (familiar with facility): 1''Ip1:.?'iy ?u??pG?? Title: 47-121Q51 C>EVT <br />Phone Number:( 970 1 •Z 3221 Fax No.:S 177v 1 Z'? 3 - 97 5- 7 <br />Who is applying for the permit? G Owner perator <br />2. Name and address of property owner. <br />Name: Gl. / F`l r011I S/' M IT}T1O10 T- /r?-I-RtG7- <br />Mailing Address : 32-1-7 1>-OA.D <br />City, State and Zip Code : GL/ TAO LV eno BISZo <br />1 ?37 2 6 6-8 <br />Phone Number : (/ 7171 ??? ` 77'2-2-- Fax No.: (PO <br />Location of the facility: T / <br />Street Address: 52. ! a 4 1 ) `Z Z?oAD <br />City, State and Zip Code: GL / ??- 1V ?, L S/S2- U <br />County: IV"A Name of facility : 32- I/Z' 1?!OAJ> 4-;,eA VEL- (7 <br />°03' 6-2 y & PI <br />Latitude and Longitude: 39 w <br />Legal Location (Township, Range, section, 1/4 section): 5E f¢ t, 3 E Il? SEGT701t12-3 'r'(6- u•lE lh? A?tEQtD/An/