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COLORADO DEPAR'I'MENTOF PUBLIC liEAL'I'l I AND ENVIRONINIENT May 13. 2009 <br />!hater Quality Control Division <br />WQC D -P -133 <br />4300 Cherry Creek Drive South <br />Denver, CO 80316 -1530 <br />SAND AND GRAVEL STORMWATER DISC'NARCE PERMIT- STORMWATER CERTIFICATION <br />APPLICATION & RECORD VERIFICATION FORM <br />(CDPS General Permit COR340000) <br />Colorado Dept of Transportation - B )L M - Burnt Shale Pit <br />This form is used to apply for coverage under the CDPS General Permit for Stornnvater Discharges Associated with Sand and <br />Gravel Mining and Processing (and other Nonmetallic ;Minerals except Fuel). COR340000, for the B L M - Burnt Shale Pit <br />facility (COR320025). Application is accomplished %hen the Division receives a completed and signed form. To apply using <br />this simplified method, and to avoid a gap in coverage for this facility, this fonn must be returned to the Division by September <br />30, 2009. Do not send any mone.- with this form - the billing process is handled separately. Additional information about this <br />process is contained in the cover letter and Q &A that accompany this form. <br />* *RETAIN A COPY OF THIS FORM FOR YOUR RECORDS** <br />To assist its in improving communication with our pennittees, please provide entail addresses for the following contacts, if <br />1 available: i <br />l :mail of l.c?all[ Rc.txmst6lc Person (teem .i, bcloR=f - ���; ;} z '; ln r (A � f . S pct e , u,:, t_ -is <br />l • • 1'KQ% WL L >I.VL ADDRESS I IL'RL 1 <br />A � <br />B. I :mats oC Local Contact (item 12, below - � j? ��1. -� +, !fit? r'?�nZc'_Y- (�) t?l`e" + {, �'afl't' ey L t a <br />PROI'It)r: fU X11- 41)DRFSS Hf RG <br />The following information reflects the Division's current records for the B L M - Burnt ,Shale Pit faeillty. Please review the <br />information carefully, and mal4e necessary changes br crossing out the Incorrect information and writing in the new; then sign the 1 <br />form below. <br />Perniittee information, including name of legalh' responsible person who is signing this form: <br />1 1. Pemlittee - Colorado Dept of Transportation <br />T- amara4- #3mith; <br />3. Phone <br />4.'\IRilingAddress 1336 -5 Co SgeQ.l, -vo `5,'ritbJt--x`� <br />Deaver-eQ -*em- (-. rzCt-no ,I t_wc yf'1('n. Cat 't <br />A'ante, location and description of Industrial activio for permitted facility: <br />5. Facihu\- Natne - B L M - Burnt Shale Pit <br />6. Facility address /Locauon - <br />, CO 81650 <br />1. hacilin' County - Garfield <br />8. Latitude / Longitude - 39/28/10 / 108146/15 <br />9. Description of .lcriririe. - Dry open pit. Sand and gravel mining and crushing. The pit is <br />operated 12 months a year, on an as needed basis. <br />Local eontaetfamiliar with the site. <br />10, local Contact <br />11. Local Contact Phone <br />Stormwater Discharges to. <br />12. Receh ine Streams) <br />Weldon-aeklrlen.- ,�jivtcii :" i <br />s70i tea s.- U ,~- - �� <br />, East Salt Creek <br />1.4. To complete this application, the Legally Responsible Person named above must sign the following certification: <br />1 Ccrt ji tender peiudh' U.l !alt• that I I1l1FC pel'SDiialil' C'Cantlried gird al)t fCtnillhar lt'Itln the !! fOPrilCltf071 s1rIJt1litted on this form and that I <br />believe that the information is trice• accurate and complete. rusher, I understand that ibt• completing and relurning this form, I have <br />applied for coverage hander the CUPS General Pernri! far .Sturtinvaler Discharges Associaied tvlth Sand and Gravel Miming and <br />Processing tune! other Nonmetallic Minerals except Fueh, COR340000. and certified then a .SFVIfP has been prepared for the <br />referenced f ivilih- that complies with all CDPS General Permit COR340000 reyuir-emenl-�. s Q <br />Al <br />Signature of Legally Responsible Person Prinlad Name Date Signed <br />