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4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include tip to foul`, in order of importance.) <br />t)r b) ??) c) d) <br />5. Receiving Stream: The name of the receiving stream(s), (If discharge is to it ditch or storm sewer, aIs include the name of <br />the IIItItllate receiving waters') LF'f.4. ?lC? .L c? (1 `[',,'/rt-,, I`y 6 t tfiu'y' J? <br />6. Describe the Industrial activities which take place on site, <br />6 <br />--??'1+?i ?- t. /??e:•"(? illi?I?>lt} ?' i?? c.'t" ?•'_?.?; r:1?1 ('c?? C ?"t" / r. <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 p)'ogratlls'? <br />a) Colorado Discharge Permit System (CDPS or NPDLS) _k _ <br />b) Colorado Mined Land Reclamation Board <br />If Yes, include MLRB permit anniversary date t y>T' - /It'd - <br />S. STORNIVNIX'CR MANAGENICNT PLAN <br />A Stornmater Management Plan (SWMP) shall Le prepared prior to aPP/loatloa fol' coverage under it 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 Storrnwater 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 SWIVIP is, to the best of my knowledge and belief, n•tic, <br />accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said MAP, <br />me ling the poss tit gf e at>pri lent. <br />Signature of Permit Applican <br />(printed) <br />c). Signature of Applicant (legally responsible person) <br />Title <br />"i certify under penalty of law that i have personally examined and am familial- with the information submitted in this application <br />and Ill stttachnlents and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I <br />believe that the intormation is true, accurate and complete, t Anl Aware that there are significant penalties for submitting false <br />ration, includill 'ossibility of tine and imprisonment,", <br /> <br />Signature ot'Permit Applicant <br />Date Signed <br />1? ??+u? S ?A tL .?„? ?yL S -mot. T2 C ?4 s <br />Name (printecl) Ale <br />i I Ict3lsg <br />-2- <br />7 a a- o <br />Date Signed