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GENERAL PERMIT APPLICATION FOR AGENCY USE ONLY <br /> STORMWATER DISCHARGES Certification Number <br /> ASSOCIATED WITH: C 1 O 1 R - 0 <br /> LIGHT INDUSTRIAL ACTIVITY <br /> (Permit No. COR-0100W) Date Received Fee Category <br /> HEAVY INDUSTRIAL ACTIVITY <br /> (Permit No. COR-020000) Year Month Day <br /> METAL MINING (Permit No. COR-040000) <br /> Please print or type. Do not attempt to complete this form before reading the instructions. <br /> 1. Name and address of permit applicant: <br /> Company Name: <br /> Federal Taxpayer (or Employer) ID#: <br /> Mailing Address: <br /> City, State and Zip Code: <br /> Phone Number: ( 1 Who is applying for the permit? ❑ Owner ❑ Operator <br /> Local Contact (familiar with facility): <br /> Title: Phone Number: ( ) <br /> 2. Location of the facility: <br /> Street Address: <br /> City, State and Zip Code: <br /> County: Name of facility: <br /> Legal Location (Township, Range, section, 1/4 section): <br /> Latitude and Longitude: <br /> Type of Facility: ❑ New (beginning operations after 10/1/92) ❑ Existing (as of 10/1/92) <br /> 3. Standard Industrial Classification (SIC) Code(s) for this facility. (Include up to four, in order of importance.) <br /> a) b) c) d) <br /> 4. Permit Category: Under which stormwater general permit does this facility belong? (See Appendix A.) <br /> ❑ Heavy Industry ❑ Light Industry ❑ Metal Mining (or Coal - see Instructions) <br /> Mines only: MLRB permit anniversary date . Which category is your facility under? <br /> ❑ Active mine, less than 10 acres ❑ Active mine, 10 acres or more ❑ Inactive mine <br /> 5. Receiving Stream: The name of the receiving stream(s). (If discharge is to a ditch or storm sewer, also include the <br /> name of the ultimate receiving waters). <br /> 7/96nhm -1- <br />