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Land Development APEN <br />Form APCD-223 <br />J&V Air Pollutant Emission Notice (APEN) and <br />Application for Construction Permit <br />All sections of this APEN and application must be completed for both new and existing developments, including <br />APEN updates. An application with missing information may be determined incomplete and may be returned or <br />result in longer application processing times. You may be charged an additional APEN fee if the APEN is filled out <br />incorrectly or is missing information and requires re -submittal. <br />This APEN is to be used for land development activities only. If your activity does not fall into this category, there <br />may be a more specific APEN for your source. In particular, if your activity features excavation of commercially - <br />sold material, you must use form APCD-222 for mining operations. A list of all available APEN forms can be found <br />on the Air Pollution Control Division (APCD) website at: www.colorado.gov/cdphe/apcd. <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 />Permit Number: AIRS ID Number: <br />[Leave blank unless APCD has already assigned a permit 4 and AIRS ID] <br />Section 1 - Administrative Information <br />Company Name': Moffat County Mining, LLC Permit Contact: Jerry Nettleton <br />Mailing Address: 29515 RCR 27 970.870.2712 <br />(Include Zip Code) Phone Number: <br />Oak Creek, CO 80467 E -Mail AddressZ: inettleton@peabodyenergy.com <br />Section 2- Requested Action <br />Q NEW land development construction permit (and check one below) <br />F1 Request coverage under construction permit Q Request coverage under General Permit GP03 <br />If General Permit coverage is requested, only pages one and two are required. <br />In addition to the APEN filing fee ($152.90), a General Permit fee of $50.00 will be assessed. <br />-OR - <br />MODIFICATION to existing permit (check each box below that applies) <br />F] Increase size of project F-1 Increase duration of project <br />-OR - <br />APEN submittal for update only (Please note blank APENs will not be accepted) <br />Additional Info at Notes: <br />Please use the full, legal company name registered with the Colorado Secretary of State. This is the company name that will <br />appear on all documents issued by the APCD. Any changes will require additional paperwork. <br />Permits, exemption letters, and any processing invoices will be issued by APCD via e-mail to the address provided. <br />Form APCD 223 Development APEN <br />p 375233 1 1 Land Develo COLORADO <br />��' 6Fn <br />