2013-01-25_INSPECTION - M1983141

• Permit No: M1983141
• IBM Index Class Name: INSPECTION
• Doc Date: 1/25/2013
• Doc Name: DISCHARGE PERMIT APPLICATION
• From: GOLD HILL MINES
• To: DRMS
• Email Name: MAC
• Media Type: D
• Archive: No

APPLICATION for DISCHARGES ASSOCIATED WITH HARDROCK MINING AND /OR MILLING
2) DMR COGNIZANT OFFICIAL (i.e. authorized agent) the person or position authorized to sign and certify reports required by permits
including Discharge Monitoring Reports [DMR's], Annual Reports, Compliance Schedule submittals, and other information
requested by the Division. The Division will transmit pre - printed reports (ie. DMR's) to this person. If more than one, please add
additional pages.
• Same As 1) Permittee
Responsible Position (Title):
Currently Held By (Person):
Telephone No:
email address
Organization:
Mailing Address:
City: State: Zip:
Per Regulation 61 : All reports required by permits, and other information requested by the Division shall be signed by the
permittee or by a duly authorized representative of that person. A person is a duly authorized representative only if:
(i) The authorization is made in writing by the permittee
(ii) The authorization specifies either an individual or a position having responsibility for the overall operation of the
regulated facility or activity such as the position of plant manager, operator of a well or a well field, superintendent, position
of equivalent responsibility, or an individual or position having overall responsibility for environmental matters for the
company. (A duly authorized representative may thus be either a named individual or any individual occupying a named
position)
(iii) Written request is submitted to the Division
3) SITE CONTACT local contact for questions relating to the facility & discharge authorized by this permit
for the facility.
■ Same As 1) Permittee
Responsible Position (Title):
Currently Held By (Person):
Telephone No:
email address
Organization:
Mailing Address:
City: State: Zip:
4) OPERATOR in Responsible Charge. Same As 1) Permittee
Responsible Position (Title):
Currently Held By (Person):
Telephone No:
email address
Organization:
Mailing Address:
City: State: Zip:
Certification Type Certification Number
Revised 4/2011