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STATE OF COLORADO <br /> C9, <br /> <br /> <br />Dedicated to protecting and improving the health and environment of the people of Colorado 0 <br />?w/ - <br />y`? <br />4300 Cherry Creek Or- S. <br />Denver <br />lorad <br />C <br />802461530 *1= <br />' <br />. <br />, <br />o <br />o F <br />Phone (303) 692-2000 <br />TDD Line (303) 691.7700 1.?,,,,aliment <br />Colorado De <br />Located in Glendale, Colorado of Public Health <br />http:11www.cdphe.stato.oo.us and Enviroturtent <br />For Agency Use Only <br />Permit Number Assigned <br />COG50- <br />Date Received / / <br />Month Day Year <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-B2 <br />Denver, Colorado 80246-1530 <br />PERMIT INFORMATION <br />Applicant is: ? Property Owner Contractor/Operator <br />Reason for Application: NEW CERT <br />? RENEW CERT EXISTING CERT M. <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 NO ?r Product wash waters? <br />YES NO ED Maintenance/Equipment wash waters? <br />YES 01 NO 8 Transport waters (e.g. slurries)? <br />YES NO ?? Scrubber waters (Crushers or classifiers)? <br />YES ® NO Mine dewatering (groundwater and/or runoff from the mine)? <br />If the answer is 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: Strohecker Asphalt and Paving <br />Legally Responsible Person: First Name: Kip Last Name: Strohecker <br />Title: Vice President <br />Mailing Address: 13211 West Highway 160 <br />City Pagosa Springs State Colorado Zip Code 81147 <br />Phone: 9702643320 <br />Email Address: stroheckerasphalt@skywerx.com <br />Page 1 of 5 Revised 12/2009