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GENERAL PERmT APPLICATION <br />STORMWATER DISCHARGES <br />A OCIATED WITH <br />AL MINING (Permit No. COR 040000) (and <br />so Coal Mining - see Instructions) <br />For Agency Use Only C O R - 0.4 <br />Date Received: - <br />Mon& Day yaw <br />ALL APPLICANTS MUST FOLLOW THE DIRECTIONS FOR COMPLETION OF THIS FORM IN <br />PART C OF THE INSTRUCTIONS <br />Please print or type. All items must be completed accurately and in their entirety or the application will be deemed incomplete <br />and the application returned. Processing of the application will not begin until all information is received. Please refer to the <br />instructions for information about the required items. Original signatures for items 7 and S are required. <br />1. Name and address of the Hermit applicant: <br />Company Name dVO9-F <br />??nn <br />Mailing Address <br />City, state and Zip Code- <br />Phone Number 03) 61 / 4 3°Z 3 <br />co 90ysa <br />Who is applying Owner Operator <br />Local Contact (familiar with facility) q <br />Title VimPhone Number <br />Local Contact E-mail Address ??/?if QC? A' ?- <br />• Legally Responsible Person (application signer) E-mail Address (SAI-? E <br />2. Location of the Facility: <br />Street AddressQ <br />City, State, and Zip Code S??' ?O $Dy,S? <br />County CLOW C!Q ? Name of Facility t?i?LLL ?GI L C/? /`7?1L?$/?E <br />LatitudelLongitude - use one of the following formats: '' <br />Latitude 3 2 / ?? j a Longitude / ? S 3 °Z I 0_(e.&,39.42,11", 104055'57") <br />seconds <br />-or- degrees minutes seconds degrees <br />Latitude - , - Longitude _,_ _ _ • _ __ _ (e.g., 39.703°,104.933°') <br />degrees (to 3 decimal places) degrees (to 3 decimal places) <br />3. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to three, in order of importance.) <br />a) ----Z© b) . c) <br />4. permit Category: Under which mining category does this facility belong? (See Appendix A.) <br />(MetW:al?Miining Coal <br />Mine Category: Which category is your facility under? <br />Active mine, less than 10 acres Active mine, 10 acres or more inactive mine <br />Colorado Division of Reclamation, Mining and Safety Permit Number (if applicable): <br />I of 2 <br />310T/MM