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4. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br />a) IVO b) /I c) 1jlz d) <br />5. Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the name <br />of the?ltimate receiving waters.) ZkLw ?2?=5-=Wi,, 12,Gr&A,' <br />6. Describe the industrial activities which take place on site. <br />al-/- amll <br />Ell <br />r'' ??S?r/l.?r ? SG/??!? rN? oi? ?? TIC , y/ ?/?g y? `lsf?r?" <br />7. Other Environmental Permits: Does this facility currently have any environmental permits, or is it subject to <br />regulation, under either of the following programs? <br />No Yes Permit # <br />a) Colorado Discharge Permit System (CDPS or NPDES) .- - <br />b) Colorado Mined Land Reclamation Board _ k41 -05 <br />If Yes, include MLRB permit anniversary date <br />8. STORMWATER MANAGEMENT PLAN <br />A Stormwater Management Plan (SWMP) shall be prepared prior to application for coverage under a general permit, and <br />the 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, <br />true, accurate, and complete. I am aware that there are significant penalties for falsely certifying the completion of said <br />SWMP, including the possibility of fine and imprisonment." <br />-11-zeDy, <br />Name <br />of Perm itApplicant <br />9. Signature of Applicant (legally responsible person) <br />"I certify under penalty of law that I have personally examined and am familiar with the information submitted in this <br />application and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the <br />information, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for <br />submitting false information, including the possibility of fine and imprisonment." <br />-//- rev' <br />Name <br />7/93/sg <br />Date Signed <br />itle <br />of Permit/Avolicant <br /> <br />Date Signed <br />-2-