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FOR AGENCY USE ONLY <br />PROCESS WATER AND STORMWATER <br />DISCHARGES ASSOCIATED WITH =CO <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC MINERALS <br />EXCEPT FUEL) <br />YEAR <br />TYPE <br />2. <br />3 <br />PERMIT NUMBER <br />DATE RECEIVED <br />MONTH I DAY <br />P S <br />Please print or type. Do not attempt to complete this form before reading the instructions. <br />New G or Renewal V If renewal, existing permit number: CO <br />I. Name and address of permit applicant: <br />Company Name: M A COIJGP_t?1'? L <br />Federal Taxpayer (or Employer) ID#: r9 1 0 9 0? 6 Q 1 <br />Mailing Address : Z 3 Z 3 IZ.I VF- V- ROAn <br />City, State and Zip Code : 5gAAIJD .,uNe-T701?1? ?-U ?ISOS <br />Phone Number: (p` 701 24-a --327-1 <br />Local Contact (familiar with facility): IVIAI IC?r/N ??I?1?/?I? +r?R? Title: `tom r= <br />Phone Number: (I70 )X43 3Z2 / Fax No.: ( q 7V ) Z'? 3 " <br />Who is applying for the permit? G Owner C7K Aerator <br />Name and address of property owner. <br />Name: 4f4 / F `I-'?O SIT IT)TrIOV S.T21G7- <br />1CZ T- <br />Mailing Address : J2- / -7 - <br />City, State and Zip Code : GL?/l ?T &j CQ B?SZO ,/ <br />Phone Number : (?70) 43,1'- 77AQ "2.2- Fax No.: (PO <br />1 ?37 ? Z 6 Sg <br />Location of the facility:: p 7-? / <br />Street Address: _ 32 ! {? l2- AP <br />_GL-? ?TOIV CQ/?j L U <br />City, State and Zip Code: <br />s <br />County: /4197sA Name of facility: 32- //z-- ?04D ?-7 APEL- T'?fT <br />0 Legal Location (Township, Range, section, 1/4 section): 5E f¢ ?E l?¢ 5E'GT70IU 23 -[-'('j Q.1 E l MET«W <br />Latitude and Longitude:_ O03/5-2 y Q80 26 ?f' I t W <br />3