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HomeMy WebLinkAboutWater Quality Control Report 08.03.2015STATE OF COLORADO Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr S. Denver, Colorado 60246.1530 Phone (303) 892.2000 TDD Line (303)691.7700 Located in Glendale, Colorado Laboratory Services Division 6100 Lowry Blvd. Denver, Colorado 802306920 (303)692-3090 Colorado Department of Public Health hup:l www.cdpha.statteo.us and Environment DIVISION USE ONLY WQCD Division Initiated Modification Requested by Date requested Date entered MODIFICATION APPLICATION Please print or type all information. All items must be filled out completely and correctly. If the form is not complete, it will be returned. All modification dates are established by the Division. This form is for modifying an established permit or certification. Terminations, Change of Contacts, Transfer of Permit, and Withdraw) of Permit Application and/or modification requests must be submitted on the appropriate form: MAIL ORIGINAL FORM WITH INK SIGNATURES TO THE FOLLOWING ADDRESS: Colorado Dept of Public Health and Environment Water Quality Control Division 4300 Cherry Creek Dr South WQCD-P-B2 Denver, CO 80246-1530 FAXED or EMAILED FORMS WILL NOT BE ACCEPTED. • PART A. IDENTIFICATION OF PERMIT Please write the permit number to be modified PERMIT NUMBER COR03M749 • PART B. PERMITEE INFORMATION (application must be signed by the legal contact listed here) SE/Z Construction LLC Company Name Mailing Address city Legal Contact Name Title 705 John Adams Parkway Idaho Falls Steve Zambarano Owner State ID Zipcode 83401 Number Phon(208)528-9449 e Email steve_zambarano@sezconstruction.com • PART C. FACILITY/PROJECT INFORMATION Facility/ProjectName Glenwood Springs FedEx Ground Manual Station #816 Location (address) City Local Contact Name Title County Road 154 near Colorado State HWY 82 Glenwood Springs Steve Zambarano Owner County Garfield Phone Number 208-681-8424 Email stave zambarano©sezconstruction.com Page 1 of 2 form last revised December 2011 COLORADO WATER QUALITY CONTROL DIVISION MODIFICATION APPLICATION www.coloradowaterpermits.com • PART D. DESCRIPTION OF MODIFICATION REQUESTED: Location has changed. New location is County Road 154 near Colorado State HWY 82, Eastbank, Glenwood Springs, Garfield County, Colorado. A permanent address has not yet been assigned. • PART E. CERTIFICATION Required Signatures 1 certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine or imprisonment. "I understand that submittal of this application is for coverage under the State of Colorado Discharge Permit System until such time as the application is amended or the certification is transferred, inactivated, or expired." 272/i - Steve Zambarano Owner Name (printed) Title *This modification application shall be signed, dated, and certified for accuracy by the permittee. In all cases, it shall be signed as follows: 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. in the case of a partnership, by a general partner; 3. In the case of a sole proprietorship, by the proprietor; 4. In the case of a municipal, state, or other public operation, by either a principal executive officer, ranking elected official, or other duly authorized employee. Page 2 of 2 form last revised December 2011