Laserfiche WebLink
Permit Number: AIRS ID Number: <br /> [Leave blank unless APCD has already assigned a permit 9;and AIRS ID] <br /> Section 7- Applicant Certification <br /> I hereby certify that all information contained herein and information submitted with this application is complete, <br /> true, and correct. <br /> °c 11ZJzo;'�' <br /> ig lure of I.A ally Authorized Person(not a vendor or consultant) Date <br /> _ 0 <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 boxes 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 $191.13 to: For more information or assistance call: <br /> Colorado Department of Public Health and Environment Small Business Assistance Program <br /> Air Pollution Control Division (303)692-3175 or(303)692.3148 <br /> APCD-SS-B1 <br /> 4300 Cherry Creek Drive South APCD Main Phone Number <br /> Denver, CO 80246-1530 (303) 692-3150 <br /> Make check payable to: Or visit the APCD website at: <br /> Colorado Department of Public Health and Environment https://www.colorado.Qov/cdahe/apcd <br /> COLORADO <br /> Form APCD-221 -Crusher/Screen APEN - Revision 3/2019 4 1 <br />