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Permit Humber: AIRS ID Number. <br />(Leave blank unless APCD has already assigned a permit # and AIRS ID) <br />Section 6 - Applicant Certification <br />I hereby certify that all information contained herein and information submitted with this application is complete, true <br />and oared. / _ / <br />— �ff Y/ I � 1)-r' 10 <br />SignaturWof Legailty Adthortwd Person (not a vendor or consultant) Date <br />Jared Graff Manager <br />Name (print) Title <br />Check the appropriate box to request a copy of the: <br />❑ Draft permit prior to issuance <br />❑ Draft permit prior to public notice <br />(Checking any of these bom may result in an increased fee and/or processing time) <br />This emission notice is valid for five (5) years. Submission of a revised APEN is required 30 days prior to expiration <br />of the five-year term, or when a reportable change is made (significant emissions increase, increase production, <br />new equipment, change in fuel type, etc.). See Regulation No. 3, Part A, II.C. for revised APEN requirements. <br />Send this form along with 5752.90 to: <br />Colorado Department of Public Health and <br />Environment <br />Air Pollution Control Division <br />APCD-5S-B7 <br />4300 Cherry Creels Drive South <br />Denver. CO 80246-1530 <br />Make check payable to: <br />Colorado Department of PubUc Health and Environ <br />ment <br />Telephone: (303) M-3150 <br />For more information or assistance call: <br />Small Business Assistance Program <br />(303) 692-3175 or (303) 692-3148 <br />Or visit the APCD website at: <br />https://www.cotarado.gav/cdphe/aped <br />1 COL OIIAOO <br />Farm APCD-22Z Mining Operations APEN - Revision 7; 2017 8 I », . <br />