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��- r.)-1‘1 l � ° -�'^ t Arc <br />STATE OF COLORADO <br />Dedicated to protecting and uaprovng the health and environment of the 1E3cLEIVED <br />4300 Cherry Greet( Dr. S <br />Denver Colorado 80246.1530 <br />Phone (303) 692 -2000 <br />TDD Lure (D3) 691 -7700 <br />Located o Glendale, Colorado <br />http +'www cdphe.state.co us <br />ttt 6 <br />I 2 5 20 <br />Colorado Department <br />of Public Health <br />� t <br />and Enoiroament <br />BY <br />CDPH MAC'_ ROOM <br />APPLICATION for DISCHARGES ASSOCIATED WITH HARDROCK MINING AND /OR MILLING <br />Please print or type. Original signatures are required. This application must be considered complete by the Division before it will <br />initiate permit processing. The Division will notify the applicant if additional information is needed to complete the application. If more <br />space is required to answer any question, please attach additional sheets to the application form. Applications must be mailed or delivered <br />to: <br />Colorado Department of Public Health and Environment <br />Water Quality Control Division <br />4300 Cherry Creek Drive South <br />WQCD -P -B2 <br />Denver, Colorado 80246 -1530 <br />PHOTO COPIES, FAXED COPIES, AND PDF COPIES WILL NOT BE ACCEPTED. <br />Reason for Application: ® NEW CERT <br />❑ RENEW CERT EXISTING PERMIT or CERT # <br />PERMIT INFORMATION <br />Applicant is: ❑ Property Owner Contractor /Operator <br />IS THIS THE CORRECT APPLICATION FOR YOUR FACILITY? <br />This application is for use by all hardrock mining and /or milling with process water and/or stormwater discharges. <br />It is applicable for both general and individual permit coverage. The Division has other industry- specific permits including: <br />sand & gravel mining, construction dewatering, gasoline clean up sites, water treatment plants, hardrock mining /milling, placer <br />mining and minimal discharge. <br />It is suggested that the applicant contact the Division of Mining & Geology at the Colorado Dept of Natural Resources, concerning <br />reclamation rules and regulations at(303) 866 -3567 <br />A. CONTACT INFORMATION <br />PERMITTEE (If more than one please add additional pages) <br />ORGANIZATION FORMAL NAME: Gold Hill Mines, Inc. <br />1) PERMITTEE the person authorized to sign and certify the permit application. This person receives all <br />permit correspondences and is legally responsible for compliance with the permit. <br />Responsible Position (Title): President <br />Currently Held By (Person): Mark A. Steen <br />Telephone No: (303)65 -2985 <br />email address goldtontine @gmail.com <br />RECEIVED <br />JAN 2 8 2013 <br />DIVISION OF RECLAMATION <br />MININGAND SAFETY — <br />For Agency Use Only <br />Permit Number Assigned <br />CO- <br />Date Received / / <br />Month Day Year <br />Organization: <br />Mailing Address: P.O. Box 1523 <br />City, Longmont State: CO Zi 80502 <br />This form must be signed by the Permittee to be considered complete. <br />Per Regulation 61 In all cases, it shall be signed as follows: <br />a) In the case of corporations, by a responsible corporate officer. For the purposes of this section, the responsible corporate <br />officer is responsible for the overall operation of the facility from which the discharge described in the application originates. <br />b) In the case of a partnership, by a general partner. <br />c) In the case of a sole proprietorship, by the proprietor. <br />d) In the case of a municipal, state, or other public facility, by either a principal executive officer or ranking elected official <br />Revised 4/2011 <br />