COLORADO

A.T

Department of Public
!

Health & Environment

;

Dedicated to

protecting

Colorado Water

and

IYIM_.

improving the health

and environment of the

Quality Control Division

people

Notice of Withdrawal of

www.coloradowaterpermits.com
Please print

or

withdraw

permi~&licati~
2018
fJ,
OlJlI~.

completely and correctly. If th/~ hnot
of permit application dates are effective on the date approv~by the

type all information. All items must be filled

complete, it will be returned. All
Water Quality Control Division.

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4Ur,. -V

of Colorado

out

FAXED or EMAILED FORMS WILL NOT BE ACCEPTED. MAIL ORIGINAL FORM WITH INK SIGNATURES TO THE

FOLLOWING ADDRESS:

Colorado Dept of Public Health and Environment
Water

Quality Control Division

4300 Cherry Creek Drive South WQCD-P-B2

Denver, CO 80246-1530
PART A.IDENTIFICATION OF PERMIT APPLICATION TO BE WITHDRAWN

~:~INATION
Permit

r

Certification number

o AMENDMENT REQUESTED FOR EXISTING

PERMIT or CERTIFICATION

Permit or Certification number

P,ART B. PERMITEE INFORMATION

.

Company

Name

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Mailing Address

Name

Title

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City

Legal Contact

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State

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PART C. FACILITY/PROJECT INFORMATION

Facility/Project
Location

Name

(address)
City

Local Contact Name

Title

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9182/22/88

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 Colorado Water

Quality Control

Division Notice of Witll"..J of Permit 4H1ication

www.coloradowaterpermits.com

PART D. PURPOSE OF WITHDRAWAL REQUEST

.

.

o-DISCHARGE WILL NOT BE CREATED AT THIS FACILITY/SITE

CHANGE OF PLANS ELIMINATE NEED

-

FOR DISCHARGE

o OTHER DISPOSAL OPTION TAKEN (DESCRIBE-ie LOW RISK POLICY...)

o DUPLICATE APPLICATION SUBMITTED

--

PERMIT PREVIOUSLY ISSUED

(LIST PERMIT NUMBER)

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PART E. CERTIFICATION SIGNATURE REQUIRED FOR ALL WITHDRAWAL OF APPLICATION REQUESTS
"I

certify

under

penalty of law that 1 have personally examined and

request and that, based

on

my

possibility

of fine

or

familiar with the information submitted in this withdrawal

inquiry of those individuals immediately responsible for obtaining the information, 1 believe that the

information is true, accurate and
the

am

complete.

1

am aware

that there

are

significant penalties for submitting false information, including

imprisonment.

~v-1\A.~<r (
Signature of Legally Responsible

Pa

Date

13rCA.c..~ (’\A1o::~t..r(
Name

[J-{(.- {h

’1

(printed)

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(\.A-A

Title

Signed

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*This withdrawal of permit application request shall be signedj dated, and certified for accuracy by the permittee in
accord with the following criteria:
1.

In the

case

of a corporation, by

a

principal

executive officer of at least the level of vice-president, or his

or

her

duly authorized representative, if such representative is responsible for the overall operation of the operation
from which the discharge described herein originates;
2.
3.
4.

In the

of a

partnership, by

general partner;
case
proprietorship, by the proprietor;
In the case of a municipal, state, or other public operation, by
elected official, or other duly authorized employee.
Form updated November 2009
In the

case

a

of a sole

wither

a

principal

executive

9182/22/88

officer, ranking

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65:88:P1 peuu~~s