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APPLICATION FOR CONSTRUCTION PER,NIIT OR PERMI•ODIFICATION <br /> (previously referred to as EMISSION PERRIU <br /> This application must be filled out completely except for N l4 and N 15: otherwise, application will be considered incomplete <br /> SEE INSTRUCTIONS ON REVERSE SIDE. Mail completed application, APENs, and filing fee to: <br /> Colorado Department of Public Health and Environment <br /> Air Pollution Control Division <br /> 4300 Cherry Creek Drive South, APCD-SS-B1 <br /> Denver, Colorado 80246-1530 Telephone: (303)692-3150 <br /> 1. Permit to be issuea to: <br /> r3C49D S <br /> 2. Mailing Address: State: CO <br /> 6iS AL'o�(/ .9uc (i4.UOAl clry Zip Code: a /Z/Z <br /> 3a. Agent for Service (See No. 3 on reverse): FjQc44ox r61:zWN Rmi2A /o,lc 2 5 <br /> 3b. Federal Tax Identification Number: 6-'COO ' 765 <br /> 4a. General Nature of Business: 4b. SIC Code: <br /> Grr�4l/cL. �Y//Nt; <br /> 5a. Air Pollution Source Description: 5b. Days per year source will <br /> I rQv1 )-_ `EL ZeIZ C/i.'6&<(1A,6 operate: OO <br /> 6a. Source Location Address (Include Location Map): /3.Rs/X�S � ' O f 6b. UTM Coordinates (in km) <br /> CN*-4c,7Y, r;/o,z-ado. v�5' ¢H y_,zS8.(Vv <br /> C iy�,&-m ZX<,; T,Zo S, /Z 7/4/, 61�`PM, <br /> (If using Township sad RRnlit.give eirectiorn and eimnce from nurM sown or Inrenealon.) County:�,,-Z—Wot/ <br /> 7. ESTD4ATED COSTS: Air Pollution Control Procedures or Equipment <br /> 7a. Source, Process Equipment or Project: 7b. Capita! Cost; $ <br /> Cap. Cost$ 7c. Operating Cost: $ <br /> 8a. STAfUS <br /> )[ New Air Pollution Source <br /> ❑ Modification to Permitted Source (Control Equipmenu added, process change, etc.): <br /> ❑ Transfer of 0wt7ership — Transferred from: <br /> ❑ Existing Source-not permitted(Include Date of Source Stan-up): <br /> ❑ Requesting to limit a source's Potential to Emit for criteria or Hazardous Air Pollutants using Regulation No. 3 (for new and <br /> existing sources) <br /> ❑ Requesting to iimit a source's Potential to Emit f'or Hazardous Air Pollutants only using Regulation No. 8 (for existing sources <br /> only) <br /> ❑ Other: <br /> Projected Dates for Construction to: <br /> 8d. Projected Source Startup Date: <br /> 8b. Begin: Zoo/ 8e. End: Z0,2.5 <br /> 9. Enclose check to cover APEN FILING FEES. One APEN should be filed for each emission point <br /> i NOTE: Additional processing fees must also be paid prior to permit issuance. <br /> AP'ENS @ $100.00 per APEN = $ <br /> �10. SIGNA71RE OFLEGALLY7Jd4 AUT RIZED PERSON(� Vendor or l la. Date Signed: 11b. <br /> Equipcturer) Phone:( <br /> ) <br /> S�/�al Fax: ( ) <br /> l2. Type or P ' na ,a d offtcia e of person signing item 10, for Agency Use Only <br /> 14, DATE RECEIVED <br /> 13. Check appropriate box It you want: 15. PERMIT NUMBER <br /> A. O Copy of preliminary analysis conducted by Division <br /> b. ❑ To review a draft of the permit prior to issuance <br /> it PIIF()RMS 9RAV'P�APPN eRA- <br />