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Permit Number: 1 OR01 1 75 <br />AIRS ID Number: 006 <br />ection 9 - Applicant Certification <br />I hereby certify that all information contained herein and information submitted with this application is complete, <br />true and correct. <br />erson (not a vendor or consultant) <br />Name (print) <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 boxes may result in an increased fee and/or processing time) <br />Title <br />Date <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 $152.90 to: <br />Colorado Department of Public Health and <br />Environment <br />Air Pollution Control Division <br />APCD-SS-B 1 <br />4300 Cherry Creek Drive South <br />Denver, CO 80246-1530 <br />Make check payable to: <br />Colorado Department of Public Health and Environment <br />Telephone: (303) 692-3150 <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.colorado.gov/cdphe/apcd <br />®Ir co1oacco <br />