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Colorado Department of Public Health&Environment FOR AGENCY USE ONLY <br /> Water Quality Control Division <br /> WQCD-P-B2 REC <br /> 4300 Cherry Creek Drive South EFF <br /> Denver, Colorado 80246-1530 YEAR MONTH DAY <br /> INACTIVATION NOTICE FOR <br /> MINING STORMWATER DISCHARGE GENERAL PERMIT CERTIFICATION <br /> Please print or type. Form must be f ely. <br /> Certification Number: COR-04 O o Taxpayer ID or EIN <br /> --OR-- COG-50 <br /> Permittee(Company)Name: C y(o/l R-d o P 1 v t S 1 o a/ <br /> Permittee Address: / 3 /3 Sd e- S i/1 ea T 2 v o "1-/ S <br /> tie - teiZ, c�l���do Svc--o3 <br /> Mine/Facility Name: Cow/ /S As w /Z eta-1 n/f-Ti d.✓ C 4oN S 112-r,r.(a ✓ P—a -J- c T S <br /> Mining Site Address/Location: G n.d u e-* C It 1, C/t-es.& ¢ is i i e s c✓ . vF /Ie 1sTa.-t <br /> Re:dsrvA•le , c-,lv/1/4-0- o 6.i3 <br /> County: Contact Person: /La"t e- <br /> Reason/justification for inactivation, and description of final site stabilization. (Attach any supporting documentation, such <br /> as proof of Mined Land Reclamation Board bond release): <br /> -s e e A 7—rA c,4.c.cC <br /> I certify under penalty of law that by the date of my signature below,all disturbed soils at the identified mining site have <br /> been finally stabilized;all temporary erosion and sediment control measures have been removed; all mining and equipment <br /> maintenance waste have been disposed of properly; and all elements of the Stormwater Management Plan have been <br /> completed. <br /> I understand that by submitting this notice of inactivation,I am no longer authorized to discharge stormwater associated <br /> with mining activity by the general permit. I understand that discharging pollutants in stormwater associated with mining <br /> activities to the waters of the State of Colorado, where such discharges are not authorized by a CDPS permit,is unlawful <br /> under the Colorado Water Quality Control Act and the Clean Water Act. <br /> I certify under penalty of law that I have personally examined and am familiar with the information submitted herein, and <br /> based on my inquiry of those individuals immediately responsible for obtaining the information,I believe that the information <br /> is true,accurate and complete. I am aware that there are significant penalties for submitting false information, including the <br /> possibility of e and imprisonment. (See 18 U. .0 1001 and 33 U.S.C. 1319.) <br /> i' r � ✓ (/lam �/�� O <br /> Signature of Permit Applicant(Legally Responsible Party) Date Signed <br /> 9/97/ mame nn e MY <br />