Fill and Sign the Progress Report Manitoba Form

WATER POLLUTION CONTROL PERMIT APPLICATION for MINING, MILLING, or OTHER BENEFICIATION PROCESSES PERMIT APPLICATION FORM For Agency Use Only ) ) ) ) ) ) ) ) Application Number Date Received / Year / Month Day PLEASE READ THE ACCOMPANYING GUIDANCE PRIOR TO COMPLETING THIS FORM (Please print or type) I. Legal name, business address and telephone number of person, partnership or corporation who owns and is responsible for the facility for which this permit application is filed. For partnership or corporation, attach on a separate sheet, the legal structure of the owner including the names, addresses, and phone numbers of all officers. A. Name: B. Mailing Address: C. (1) P.O. Box or Street: (2) City: (3) (4) County: State and Zip Code: Telephone Number: ( ) Page 1 of 5 II. Legal name, business address and telephone number of person, partnership or corporation who operates and is responsible for the facility for which this permit application is filed. For partnership or corporation, attach on a separate sheet, the legal structure of the owner including the names, addresses, and phone numbers of all officers. A. Name: B. Mailing Address: C. III. (1) P.O. Box or Street: (2) City: (3) (4) County: State and Zip Code: Telephone Number: ( ) Legal name, address, and telephone number of person authorized to act on behalf of the applicant (designated agent). A. Name: B. Mailing Address: C. (1) P.O. Box or Street: (2) City: (3) (4) County: State and Zip Code: Telephone Number: ( ) Page 2 of 5 IV. Legal name, address, and telephone number of the owner of the land, mining claim or claims on which the proposed activity is planned or occurs. For partnership or corporation, attach on a separate sheet, the legal structure of the owner including the names, addresses, and phone numbers of all officers. A. Name: B. Mailing Address: C. V. P.O. Box or Street: (2) City: (3) (4) County: State and Zip Code: Telephone Number: ( ) Location of facility A. B. VI. (1) County or counties: Township, Range and Section(s): Type of facility Large-scale (All information required by NAC 445A.394 must be submitted as supporting information to this form) Small-scale (All information required by NAC 445A.410 must be submitted as supporting information to this form) Pilot or testing (All information required by NAC 445A.412 must be submitted as supporting information to this form) Physical separation (All information required by NAC 445A.414 must be submitted as supporting information to this form) Page 3 of 5 VII. Anticipated size, magnitude or extent of activity A. Acres of surface disturbance: B. Amount of ore processed in tons per year: VIII. Method(s) of ore processing: IX. Expected lifetime of activity less than one year one to five years more than five years X. Any person who knowingly makes any false statement, representation or certification in any application, record, report, plan or other document filed or required to be maintained by the provisions of NRS 445.131 to 445.354, inclusive, or by any permit, rule, regulation or order issued pursuant thereto, or who falsifies, tampers with, or knowingly renders inaccurate any monitoring device or method required to be maintained under the provisions of NRS 445.131 to 445.354, inclusive, or by any permit, rule, regulations or order issued pursuant thereto, is subject to remedies and sanctions as provided in NRS 445.317, to-wit, not more than $25,000 per day per violation or imprisonment for not more than one year or both. Page 4 of 5 XI. I certify that I am familiar with the information provided in this application and that to the best of my knowledge the information is true, complete, and accurate and that I have the authority to execute and sign this application. Printed Name of Owner Title or Authority of Signator Legal Signature Date of Signing Printed Name of Operator Title Authority of Signator Legal Signature Date of Signing Version 12.5.95 J:\FORMS\FORM.M Page 5 of 5