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If YES,specify name(s)of owners of water supply intake(if known) <br /> • t <br /> 21. Do you have any other environmental permits under any of the following programs? <br /> PermitName Yes No Applied For, Date Permit No. <br /> Colorado Division of Minerals and Geology(formerly <br /> MLRD <br /> Underground Injection Control <br /> Dredge or fill permit under Section 404 of the Clean Water <br /> Act(CWA)(Arm Corps of Engineers) <br /> Resource Conservation and Recovery Act(RCRA) <br /> CDPS Stormwater r/ /(! Z Z—Q C Dv ov 3 p6 <br /> Colorado State Air Pollution Emission' <br /> Other <br /> 22. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all <br /> attachments and that,based on my inquiry of those individuals immediately responsible for obtaining the information,I believe that the <br /> information is true,accurate and complete. I am aware that there are significant penalties for submitting false information, including the <br /> possibility of fine or imprisonment. <br /> Signature of Owner(s) Date Signed <br /> Name(printed) Title <br /> I/- 2- <br /> Signature of Operator Date Signed <br /> Name(printed) Title <br /> DEWA7EMG Il93 �4� <br />