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c ZX/H/s IT n1- (6 <br />Water Quality Control Division - Stormwater www.coloradowaterpermits.com <br />F. OTHER ENVIRONMENTAL PERMITS <br />Does this facility current) have an environmental Permits, or is it subject to regulation, under either of the following programs? <br />Permit Name Yes No Application Date Permit No. <br />a. Colorado Division of Reclamation, Mining and Safety- El 05/19/11 M-2011-029 <br />permit anniversary: <br />b. Underground Injection Control ? ? <br />C. Clean Water Act (CWA) Section 404 permit (Army <br />El <br />El <br />Corps of Engineers) <br />d. Resource Conservation and Recovery Act (RCRA) El El <br />e. Colorado Discharge Permit System (CDPS) El 1:1 <br />f. Colorado State Air Pollution Emission IN ? 05/01/11 <br />g. Other 11 El <br />G. MAP (Provide as an attachment to the application) <br />Map attached? NO e YES <br />Map: Attach a map that indicates the site location and that CLEARLY shows the boundaries of the area subject to the application. Maps <br />must be no larger than 11 x 17 inches. <br />H REQUIRED SIGNATURES (Both parts i. and ii. must be signed) <br />STO ! A Stormwater Management Plan must be complete I prior to signing the following certifications! <br />The Stormwater Management Plan (SWMP) requirement applies to all facilities. A SWMP must be prepared prior to submitting an <br />application for coverage under a stormwater discharge general permit, and the Stormwater Management Plan Certification (below) signed. <br />See the Division's website (www.coloradowaterpermits.com) for SWMP preparation guidance documents (identified by permit category - <br />heavy and light industrial activity, metal mining, or the recycling industry). <br />Note: Applications for Heavy Industrial Activity and the Recycling Industry stormwater discharge permit types must include a copy of the <br />Stormwater Management Plan. <br />Heavy Industrial Activity and the Recycling industry SWMP attached? ? NO e YES <br />i. Stormwater Management Plan Certification <br />"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with <br />a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the <br />person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted <br />is to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonment for knowing violations." <br />05/31/11 <br />Applicant or du& authorized representative signature (submission must include original ink signature) Date Signed <br />MARTIN R BAUER GENERAL PARTNER <br />Name (printed) Title <br />b-« <br />Page 4 of 8 <br />Revised 3/2011