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Water Quality Control Division—Stormwater www.coloradowaterpermits.com <br /> F. OTHER ENVIRONMENTAL PERMITS <br /> Does this facility currently have any environmental permits, or is it subject to re ulation, under either of the following programs? <br /> Permit Name Yes No Application Date Permit No. <br /> a. Colorado Division of Reclamation, Mining and Safety— <br /> permit anniversary: ❑ ❑ <br /> b. Underground Injection Control ❑ ❑ <br /> C. Clean Water Act(CWA)Section 404 permit (Army <br /> Corps of Engineers) ❑ ❑ <br /> d. Resource Conservation and Recovery Act(RCRA) <br /> e. Colorado Discharge Permit System (CDPS) ❑ ❑ <br /> f. Colorado State Air Pollution Emission <br /> g. Other <br /> G. MAP (Provide as an attachment to the application) Map attached? NO ❑ YES <br /> Map:Attach a map that indicates the site location and that CLEARLY shows the boundaries of the area subject to the application. Maps <br /> must be no larger than 11 x 17 inches. <br /> H. REQUIRED SIGNATURES(Both parts i.and ii.must be signed) <br /> STOP! A Stormwater Management Plan must be completed prior to signing the following certifications! <br /> The Stormwater Management Plan (SWMP)requirement applies to all facilities. A SWMP must be prepared prior to submitting an <br /> application for coverage under a stormwater discharge general permit, and the Stormwater Management Plan Certification (below)signed. <br /> See the Division's website(www.coloradowaterpermits.com)for SWMP preparation guidance documents(identified by permit category— <br /> heavy and light industrial activity, metal mining, or the recycling industry). <br /> Note:Applications for Heavy Industrial Activity and the Recycling Industry stormwater discharge permit types must include a copy of the <br /> Stormwater Management Plan. <br /> Heavy Industrial Activity and the Recycling industry SWMP attached? ❑ NO ❑ YES <br /> i. Stormwater Management Plan Certification <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with <br /> a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the <br /> person or persons who manage the system, or those persons directly responsible for gathering the information,the information submitted <br /> is to the best of my knowledge and belief,true,accurate and complete. I am aware that there are significant penalties for submitting false <br /> information, including the possibility of fine and imprisonment for knowing violations." <br /> Applicant or duly authorized representative signature(submission must include original ink signature) Date Signed <br /> Name(printed) Title <br /> Page 4 of 8 Revised 3/2011 <br />