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STATE OF COLORADO <br /> OF COQ <br /> c? ? Rj? <br />Dedicated to protecting and improving the health and environment of the people of Colorado <br />? <br />=: =S <br />4300 Cherry Creek Dr. S. . b. ?.+ . <br />Denver. Colorado 80246.1530 'rave' <br />Phone (303) 692.2000 <br />TDD Line (303) 691.7700 Colorado Dcpartment <br />Located in Glendale, Colorado of Public Health <br />h1lp:1Avww.cdphe.state.co.us and Environment <br />APPLICATION for DISCHARGES ASSOCIATED WITH SAND & GRAVEL MINING AND PROCESSING <br />(and other Nonmetallic Minerals except fuel) <br />Please print or type. Original signatures are required. FAXED COPIES OR PDF COPIES WILL NOT BE ACCEPTED. <br />This application must be considered complete by the Water Quality Control Division (the Division) before it will initiate permit processing. <br />The Division will notify the applicant if additional information is needed to complete the application. If more space is required to answer <br />any question, please attach additional sheets to the application form. Applications must be mailed or delivered to: <br />Colorado Department of Public Health and Environment <br />Water Quality Control Division <br />4300 Cherry Creek Drive South <br />WQCD-P-82 <br />Denver, Colorado 80246-1530 <br />PERMIT INFORMATION <br />Applicant is: ? Property Owner Contractor/Operator <br />'NEW CERT <br />Reason for Application: <br />? RENEW CERT EXISTING CERT #: <br />IS THIS THE CORRECT APPLICATION FOR YOUR FACILITY? <br />This application is for use by all industrial process water dischargers, or process water plus stormwater dischargers, engaged in sand and <br />gravel production operations (and other nonmetallic minerals, except fuels). This application is for both active and inactive mining <br />operations and concrete and asphalt batch plants at the facility. It is suggested that all applicants contact the Division of Reclamation, <br />Mining and Safety at the Colorado Department of Natural Resources, for information on their rules and regulations for Sand and Gravel <br />mining and processing. <br />Are any of the following discharged from the sand and gravel production operation subject to this application? <br />YES ?3 NO'[ Product wash waters? <br />YES NO Maintenance/Equipment wash waters? <br />YES NO Transport waters (e.g. slurries)? <br />YES ® NO Scrubber waters (Crushers or classifiers)? <br />YES; NO [3 Mine dewatering (groundwater and/or runoff from the mine)? <br />If the answer s YES to any of these questions, this is the correct application for the discharge. <br />If the answer is NO to ALL of these questions, STOP NOW, and instead, complete the application for Stormwater Discharges Associated <br />with Sand and Gravel Mining and Processing (COR340000). <br />1. CONTACT INFORMATION <br />Permit Applicant / <br />Company Name: f'V? G <br />%-T-- <br />Legally Responsible Person: First Name: (>17 Last Name: hf ?`? ?ir /4s <br />Title: <br />Mailing Address: 2.13C, L LL 5 /?' S <br />City C (1e, i State C c- Zip Code "/ . <br />Phone: 17e: . 2.4-Email Address: `?- <br />Page 1 of 5 Revised 12/2009 <br />S? c 1-t' 2 3 - l <br />For Agency Use Only <br />Permit Number Assigned <br />COG50- <br />Date Received <br />Month Day Year