2010-10-08_PERMIT FILE - M1977223

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6. NATURE OF CONSTRUCTION ACTIVITY Check the appropriate box(s) or provide a brief description that indicates the general n ature of the construction activities. (The full description of activities must be included in the Stomhwater Management Plan.) n Single Family Residential Development o Mufti-Family Residential Development a Commercial Development Oil and Gas Production and/or Exploration (including pad sites and associated infrastructure) n Highway/Road Development W including roadways associated with commercial or residential development) a Other, Describe: Reservoir and Water Transfer System 7. ANTICIPATED CONSTRUCTION SCHEDULE Construction Start Date: January 2011 Final Stabilization Date: January 2012 S. RECEIVING /MATERS (if discharge is to a ditch or storm sewer, include the name of the ultimate receiving waters) Immediate Receiving Water(s): Ultimate Receiving Water(s): Riverview Ditch and Arkansas River Arkansas River 9. REQUIRED SIGNATURES (Both parts i. and ii. must be The either the owner and/or operator of the construction site. Refer to Part B of the instructions for additional information. The application must be sinned by the applicant to be considered complete. jaA ggm, it shall be signed as follows. a) In the case of corporations, by a principal executive officer of at least the level of vice-president or his or her duly authorized representative, if such representative Is responsible for the overall operation of the facility from which the discharge described in the application originates. b) In the case of a partnership, by a general partner. c) in the case of a sole proprietorship, by the proprietor. d) In the case of a municipal, state, or other public facility, by either a principal executive officer, ranking elected official, or other duly authorized employee if such representative is responsible for the overact operation of the facility from which the discharge described in the form originates. STOPI: A_Stormwater Management Plan must be completed prior to signing the following certifica(,ionsl 1. Stormwater Management Plan Certification °I certify under penalty of taw that a complete Stormwater Management Plan, as described in Appendix A of this application, has been prepared for my activity. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the Stormwater Management Plan is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there arffZV . t penalties for falsely certifying the completion of said SWMP, including the possibility of fine and imprisonment for k a, s" t W3o 1ro or Authorized Agent Name (printed) li. Signature of Permit Legal Contact Title "1 certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine or imprisonment. °I understand that submittal of this application is for coverage under the State of Colorado General Permit for Stomnwater Discharges Associated with Construction Activity for the entirety of the construction sfoelproject described and applied for, until such time as the application is amended or the certification is transferred, inactivated, or expired.* Signature of Legally Responsible Person (submission must include original signature) Date Signed Name (printed Title Page 3 of 3 DO NOT INCLUDE A COPY OF THE STORMWATER MANAGEMENT PLAN DO NOT INCLUDE PAYMENT -AN INVOICE WILL BE SENT AFTER THE CERTIFICATION IS ISSUED. Revised 412010