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<br /> 5.'- Location of facility
<br /> Longitude /O O L Latitude'
<br /> Legal description(Township,Range, 1/4 Section)_T ly S f IL
<br /> Street? hl1"5 �"s2 9fEf-5 "'C County r-K,.,.
<br /> City State Ce 1(4w R env Zip Code
<br /> Local Contact(familiar with facility) S T e tie. ,- /Z e e/2
<br /> Telephone Number t?X) a- Title -J7,cT- /t-lR�-stGe2
<br /> Please provide directions to the operation from a nearby town or landmark.
<br /> Fi2c -r ifed.S -e� fv/tk,' ZLe57- oA- Cc,,.*-L C/!«<;
<br /> lL S Tv 4e-^_O aG /Zv tp .
<br /> 6. Type of activity: e.g.,building construction,general construction,highway bridge and tunnel construction,etc.and a description of
<br /> activities being performed,including construction schedule and months of operation. Specify source(s)of-wastewater to be discharged(i.e.
<br /> groundwater,stormwater runoff).
<br /> ,S7/Lt�t•'i C If4-rVA,e L Ce. rl4rN /}!, /1",*11 r- 'P
<br /> 12eG �?s`tii'TZo� f}-�7�rvtTl�S. ��n ST7t�cT�cK- fz�
<br /> /Se nP/e f n.o Lq-f{'Ot 741— //-2 l- Y �.
<br /> C✓4t-c 5",-A cc 15 A-A(I-Vrn
<br /> 7. Do you anticipate the need for changing or adding the discharge point(s)as construction progresses? If so,briefly explain.
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<br /> 8. A location map designating the facility property and discharge points shall be submitted. The map shall be from a 7 'h or 15 minute USGS
<br /> quad sheet or a map of comparable scale. A north arrow shall be shown. Any public water supply intakes within a 5 mile radius of the
<br /> facility shall also be identified,if known(see item 20). This map must be on paper 8 r/z x 11 inches.
<br /> 9. A legible sketch of the site shall be submitted and include appurtenant facilities(buildings,ponds,diversion ditches,etc.),stream location,
<br /> numbered discharge points,sampling and flow monitoring points. Sketch shall be on paper 8 'h x 11 inches. Label the outfalls on the
<br /> sketch to correspond with the numbers listed in 10.
<br /> 10. Will the discharge go to a ditch,storm sewer,or any other type of conveyance? ❑ YES U' NO
<br /> If YES,submit documentation that the owner of the ditch,storm sewer,or any other type of conveyance,allows this discharge. No
<br /> certification will be processed unless documentation of approval is received.
<br /> 11. Method of flow measurement for each discharge(i.e. 90'v-notch weir,pump capacity,parshall flume,etc.). Designate whether currently
<br /> installed or proposed.
<br /> _15 ,c Ke r-
<br /> 12. Do you have bulk storage of diesel fuel,.gasoline,solvents or other hazardous materials on site? EYES, ❑ NO
<br /> DEWA7EN NG 4M (`)
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