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&)*B/r (M <br />STATE OF COLORADO <br /> F ?ry <br /> <br />Dedicated to protecting and improving the health and environment of the people of Colorado nA <br />R? <br />hj? ` ' vg <br />4300 Cherry Creek Dr. S. "! , <br />= <br />=??* <br />Denver, Colorado 80246-1530 ` <br />re70 <br />Phone(303)692.2000 <br />TOO Line (303) 691.7700 Colorado Department <br />Located in Glendale, Colorado <br />of Public Health <br />m1p:/Ayww.cdphe,stale.co.U$ and E.nvironmcnt <br />, (1? <br />For Agency Use Only <br />COR- <br />Date Received <br />Month Day Year <br />REGULATION <br />WATER BODY ID <br />APPLICATION for STORMWATER DISCHARGES ASSOCIATED WITH: <br />• HEAVY and LIGHT INDUSTRIAL ACTIVITY <br />• METAL MINING (and some Coal Mining) <br />• RECYCLING INDUSTRY <br />Please print or type. Original signatures are required. FAXED COPIES O PDF COPIES WILL NOT BE ACCEPTED. <br />This application is for use by all industrial stormwater dischargers engaged in heavy and light industrial activity, metal <br />mining (and some coal mining), and the recycling industry as categorized by Standard Industrial Classification Code (SIC <br />code) (see Appendix A.) <br />The application must be submitted to the Water Quality Control Division (the Division) at least 30 days prior to the anticipated <br />date of discharge, and must be considered complete by the Division before it will begin the review and approval process. The <br />Division will notify the applicant if additional information is needed to complete the application. If more space is required to <br />answer 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 TYPE <br />Indicate the stormwater discharge permit type this application applies to. Refer to Appendix A for appropriate permit type based on the <br />primary industrial activity conducted at the facility. Note: Applications for Heavy Industrial Activity and the Recycling Industry stormwater <br />discharge permit types must include a copy of the Stormwater Management Plan. <br />? Heavy Industrial Activity (A copy of the Stormwater Management Plan must be submitted to the Division with the application.) <br />? Light Industrial Activity <br />N Metal Mining ?Inactive mine 9active over 10 acres ? active under 10 acres <br />? Recycling Industry (A copy of the Stormwater Management Plan must be submitted to the Division with the application.) <br />APPLICANT <br />The applicant must be a legal entity that meets the definition of either the owner and/or operator of the industrial activities that occur at the <br />facility for this application to legally cover the industrial activities. The applicant must have day-to-day supervision and control over <br />activities at the facility and implementation of the Stormwater Management Plan (SWMP). <br />Alternative Permittees: Other agents may also obtain permit coverage if they have clear contractual responsibility and operational control <br />to address the impacts industrial activities may have on stormwater quality (including SWMP implementation). Examples include <br />consultants or property owners acting as facility managers under contract with the owner or operator of the industrial activities, as long as <br />the contractual relationship clearly delegates responsibility for stormwater management. A property owner that is not associated with the <br />actual industrial activities at the site or under contract to adequately perform the stormwater management responsibilities at the site, as <br />discussed above, may not legally maintain permit coverage for industrial activities at their property. <br />Applicant is: ? Property Owner e Contractor/Operator <br />Page 1 of 8 2-4 Revised 3/2011