_PERMIT FILE - M2013026

• Permit No: M2013026
• IBM Index Class Name: Permit File
• Doc Name: Other Applications
• Media Type: D
• Archive: No

Water Quality Control Division—Stormwater www.coloradowaterpermits.com
Permit number COR-
a.CONTACT INFORMATION - NOT ALL CONTACT TYPES MAY APPLY * indicates required
*PERMITTEE(If more than one please add additional pages)
*ORGANIZATION FORMAL NAME:
1) *PERMITTEE the person authorized to sign and certify the permit application. This person receives all
permit correspondences and is legally responsible for compliance with the permit.
Responsible Position (Title):
Currently Held By(Person):
Telephone No:
email address
Organization:
Mailing Address:
City: State: Zip:
This form must be signed by the Permittee to be considered complete.
Per Regulation 61 In all cases,it shall be signed as follows:
a) In the case of corporations,by a responsible corporate officer. For the purposes of this section,the responsible
corporate officer is responsible for the overall operation of the facility from which the discharge described in the
application originates.
b) In the case of a partnership,by a general partner.
c) In the case of a sole proprietorship,by the proprietor.
d) In the case of a municipal,state,or other public facility,by either a principal executive officer or ranking elected official
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) Submitten in writing to the Division
Page 2 of 8 Revised 3/2011