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COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT May 13, 2009 <br />Water Quality Control Division <br />WQCD-P-B2 <br />4300 Cherry Creek Drive South <br />Denver, CO 80246-1530 <br />SAND AND GRAVEL STORMWATER DISCHARGE PERMIT - STORMWATER CERTIFICATION <br />APPLICATION & RECORD VERIFICATION FORM <br />(CUPS General Permit COR340000) <br />Colorado Dept of Transportation - B L M Pit - West of Maybell <br />This form is used to apply for coverage under the CDPS General Permit for Stormwater Discharges Associated with Sand and <br />Gravel Mining and Processing (and other Nonmetallic Minerals except Fuel), COR340000, for the B L M Pit - West of Maybell <br />facility (COR320029). Application is accomplished when the Division receives a completed and signed form. To apply using <br />this simplified method, and to avoid a gap in coverage for this facility, this form must be returned to the Division by September <br />30, 2009. Do not send any money with this form - the billing process is handled separately. Additional information about this <br />process is contained in the cover letter and Q&A that accompany this form. <br />"RETAIN A COPY OF THIS FORM FOR YOUR RECORDS** <br />To assist us in improving communication with our perntittees, please provide email addresses for the following contacts, if <br />available: <br />A. Email of Legally Responsible Person (item ;i, below) - <br />B. Email of Local Contact (item 12, below) <br />PROVIDE EMALL <br />de , M_ - us <br />PROVIDE EMAIL ADDRESS HERE <br />The following nzfor,Madan reflects the Division's current records for the B L M Pit - West of Maybell facility. Please review to <br />information carefully, and make necessary changes by crossing out the incorrect information and writing in the new; 11:en sign the <br />form below. <br />Permittee information, including name of legally responsible person who is signing this form: <br />1. Permittee - Colorado Dept of Transportation <br />Legally Responsible Person - ' l <br />3. Phone - 979¢248-4226 1 Vap-- 61 (92 Q <br />4. Nlailing Address - 1 f'00 J?k <br />B lr - OSr CZ gk (P7,5 <br />Name, location and description of industrial activiivfor permitted facility: <br />5. Facility Name - B L M Pit - West of Maybell <br />6. Facility Address/Location - <br />, CO 82321 <br />7. Facility County - Moffat <br />8. Latitude / Longitude - 40/31/00 / 108/06/40 <br />9. Description of Activities - Dry open pit. Sand and gravel mining and crushing. The pit is <br />open year-round, and used on an as needed basis. <br />Local contact familiar with the site: <br />10. Local Contact - <br />11. Local Contact Phone <br />Stormwater Discharges to: <br />12. Receiving Stream(s) - <br />Ditch <br />14. To complete this application, the Legally Responsible Person named above must sign the following certuricat?on: <br />I certify under penalty of law that 1 have personally examined and am familiar with the information submitted on this form and that I <br />believe that the information is true, accurate and complete. Further, 1 understand that by completing and returning this form, I have <br />applied for coverage under the CDPS General Perrrrit for Stormwater Discharges Associated with Sand and Gravel Mining and <br />Processing (and other Nonmetallic Minerals except Fuel), COR340000, and certified that a SWMP has been prepared for the <br />referenced facility that complies with all CDPS General Permit COR340000 requirements, <br />Signature of Legally Responsible Person <br /> <br />Printed Name <br />Date Signed <br />