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FOR AGENCY USE ONLY .`:':-FTI <br /> COAL N NG- :.. . .>:. :...: : <br /> c <br /> L d. <br /> PROCESS WATER AND STORNVIW A I ER <br /> DISCHARGE APPLICATION :.DATA RECIIVED <br /> ::YEAR:. ..-: .. ::MONTH. :- DAY <br /> T F� <br /> PLEASE PRINT OR TYPE Do not attempt to complete this form before reading the accompanying instructions. <br /> New ❑ or Renewal ® If renewal, existing permit number: CO —0 0 0 01 A F 0 j 2 9 <br /> rn <br /> 1. Name and Address of Operator: (former operator — see attached, ;it6m._ 1_)' ;.- <br /> Company Name: Mi Cnnt i rant R--;=rrFnc Tnr- <br /> Federal Taxpayer(or Employer)M#: 3 6—14 5 719 3 _ _ <br /> Mailing Address: I?n R n v S n n <br /> Ciry, State and Zip Code• Carbondale CO 81623 <br /> Phone Number: (97 0 ) P 6 3—?S R 1 Who is applying for the permit? ❑ Owner Operator (former ) <br /> Local Contact(familiar with facility): Len Ward 1 a w Title: N/A <br /> Phone Number. ( 970 961-2581 FaxNo.: (970) 963-2816 <br /> 2. Name and Address of Owner: <br /> Name: See Attached item _-2 <br /> Mailing Addr-,.ss: <br /> City, State and Zip Code: <br /> Phone Number. ( ) Fax No.: ( ) <br /> 3. Location of the Facility: <br /> Strr_t Address: 4 . 5 m i 1 G w P g t, of -0 a r7 G t n n o r n <br /> City, State and Zip Code: N <br /> County: P i t k i n Name of facility : t,n r m P r m i -a c i }a r'n a l R A C l n <br /> Legal Location(Township, Range, section, 1/4 section): -See attached___ <br /> Latitude and Longitude_ See „ <br /> 4. Corporate Structure: Please provide, on a separate sheet, the corporate structures) for those companies listed in items 1 and Z. The <br /> strucntre should extend to the ultimate parent company. In the case of a joint venture, please provide this information for each company <br /> which is part of the joint venture, as well as ownership interests. <br /> 5. Standard Industrial Classification Code(s) for this facility. (Include up to four, in order of importance.) <br /> a) 1 * b)fication ( c) d) <br /> *Mining ceased in 1991 . <br />