_GENERAL DOCUMENTS - C1981017 (303)

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COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT July 6,2006 Water Quality Control Division WQ6-P-E2 4300 Cherry Creek Drive South Denver,CO 80246-1530 METAL MINING STORMWATER DISCHARGE PERMIT REAPPLICATION&RECORD VERIFICATION FORM Colorado Div. of Minerals & Geology, Coal Basin Reclaim. Cons. PIojects This form is for reapplication for the Coal Basin Reclaim. Cons.Projects facility(COR-040204)under the Metal Mining Stormwater Discharge Permit. By filling out and signing this form and returning it to the address at the top,you will have reapplied. In order to reapply by this simplified method,and to avoid a gap in coverage for your facility,you must return this form by July 31,2006. Do not send any moneX with this form-the billing process is handled separately. More information about this process is contained in the cover letter and Q&A that accompany this form. **RETAIN A COPY OF THIS FORM FOR YOUR RECORDS** To assist us in improving communication with our permittees,please provide the following email addresses for the following contacts, if available: A. Email of Legally Responsible Person (item 3,below) - PLEASE PROVIDE EMAIL ADDRESS HERE B. Email of Local Contact (item 12,below) - PEASE PROVIDE EMAIL ADDRESS HERE This is the latest information that we have in our records for your facility. Please review the information carefully and make whatever changes are necessary,by crossing out the incorrect information and writing in the new,and sign the form below. Permittee information,including name of legally responsible person who is signing this form: 1. Perniittee - Colorado Div. of Minerals & Geology ederal Taxpayer ID Number - 840644739 3. Legally Responsible Person - David L. Bucknam, Program Supervisor 4. Phone - 303/866-3567 5. Mailing Address - 1313 Sherman Street Room 215 Denver, CO 80203 Name,location and description of industrial activity for permitted facility: 6. Facility Name - Coal Basin Reclaim. Cons. Projects 7. Facility Address/Location - End of Coal Creek Road Redstone, CO 81623- 8. Facility County - Pitkin 9. Latitude - 39/11/55 Longitude - 107/18/02 Mine Status should be one of the following categories, "Active,less than 10 acres'; "Active,10 acres or more'; or"Inactive mine". Inactive mines are mines that are no longer being actively mined. Mines that are in temporary cessation are considered active. If the status has changed from what is written below,please indicate which one of the three categories is appropriate for the facility. 10. Mine Status - Active, less than 10 acres 11. Description of Activities - Earth moving, stream channel reconstruction, topsoil application, revegetation. Local contact familiar with the site: 12. Local Contact - Steven Renner, Project Manager 13. Local Contact Phone - 970/241-0336 Storm water Discharges to: 14. Receiving Stream(s) - Dutch Creek tributary to Coal Creek 15.To complete this Reapplication,the Legally Responsible Person named above must sign the following certification: I certify under penalty of law that I have personally examined and am familiar with the information submitted on this form and that I believe that the information is true, accurate and complete. Further,I understand that by completing and returning this form, I have applied for coverage under the revised general permit for Stormwater Discharges Associated with Metal Mining Operations And Mine- Waste Remediation (COR-040000)and certified that an up-to-date Stormwater Management Plan is maintained for my facility. Signature of Legally Responsible Person Printed Name Date Signed