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<br />!~ <br />III IIIIIIIII IIII III <br />999 <br />FOR AGENCY USE ONLY <br />PROCESS WATER AND STORMWATER <br />DISCIIARGES ASSOCIATED WITH C O <br />SAND AND GRAVEL PRODUCTION <br />OPERATIONS (AND OTHER <br />NONMETALLIC ~ y <br />ExcEPT FUELr ~~CEI y EI;~~ <br />MAR 19 2001 '~'~ <br />Oitrision of Minaralr unr licotoat TYPE' <br />Please print or type. Do not attempt to complete this form before reading the inswctions. <br />New Q or Renewal ^ If renewal, existing permit number: CO <br />1. <br />2. <br />Name and address oP permit applicant: <br />Company Name: Four States Aggregates, <br />Federal Taxpayer (or Employer) tD#: 8 <br />Mailing Address : PO Box 1568 <br /> VUtBnyv ~ ~~•- - <br />- - - - - - - ~ Division of Minerals & Geology <br />City, State and Zip Code : CORTEZ, CO 51321-1568 <br />Phone Number : (970 ) 565-3388 <br />Local Contact (familiar with facility): Aryol Brumley Title: ManaKer <br />Phone Number: ( 970 ) 565-3388 Fax No.: ( 970 ) 565-1057 <br />Who is applying for the permi[? ^ Owner ~ Operator j • ; - ~ r •, _ <br />Name and address of property owner: <br />!'~ <br />Mailing Address : 22374 <br />City, State and Zip Code <br />1451 PO Box 458 <br />Dolores. CO 81323 <br />- Lt/1 <br />Phone Number : ( 970 ) 882-7383 Fax No. <br />3. Location oP the facility: <br />Street Address: 21944 <br />City, State and Zip Code: DOLORES. CO 81323 <br />County: MONTEZUMA Name of facility: LINE CAMP PIT <br />Legal Location (Township, Range, section, 1/4 section): SE '~ of NW 'ti of Sec 22, T38N, R14W, 10'" (N1v1) PM, Montezuma County <br />Latitude and Longitude: 37d 31m 47s, IOSd 22m SOs <br />4. Standard Industrial Clttssi6ration (SIC) Code(s) for this facility. (Include up to four, in order of importance. See Appendix A.) <br />a) 1442 b) <br />PERDIIT NUMBER <br />DATE RECEIVED <br />MONTH I DAY <br />P S <br />Received <br />htAR 1 `z ?~~'~ <br />LLC <br />c) <br />d) <br />•-l ~ ..a <br />r , <br />~M' ~ c--_t _._. <br />Y• -• <br />5. Receiving Stream: The name of the receiving sveam(s). (if discharge is to a ditch or storm sewer, also include the name of the ultimate <br />receiving waters.) Afield drain line discharp,ing into the Dolores River <br />