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APPLICATION FOR CONSTRUCTION PERMIT OR PER•MODIFICATION <br /> (previously referred to as EMISSION PEEM <br /> This application must be filled out completely except for#14 and#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-Bl <br /> Denver, Colorado 80246-I530 Telephone: (303)692-3150 <br /> 1. Permit to be issued to: <br /> t?iV Cr�U o Jz/ Q` <fZ_ yI�SS.I� C?S <br /> 2. Mailing Address: / State: CO <br /> 6� /�/OCr�t/ t✓c t (p� C�7 ` Zip Cade: <br /> 3a. Agent for Service (See No. 3 on reverse): �RFiy/a'Jr Ceti V7'1 �0�2 oG CCYf9✓1��S�G/!C2 S <br /> 1 3b. Federal Tax Identification Number: Sy caD " W, <br /> 4a. General Nature of Business: 4b. SIC Code: <br /> 6/l000z /Y/i�� /%Z <br /> 5a. Air Pollution Source Description: _ 5b, Days per year source will <br /> P its 4 er_00ZC2 . UZa c e operate: /S'O <br /> 6a. Source Location Address (Include Location blap):Ca'h'� ?t/ , �Pr /a'/4 5 6b. UTM Coo inat��{{1an km) <br /> /9CJV <br /> C��yT Fn s a give IZ `7 C✓ �ZVI <br /> 8 P f 4 St10 aitunce fry neara(�o or in[cnMiun.) CoUruy: <br /> 7. ESTIMATED COSTS: F7b. <br /> Pollution Control Procedures or Equipment <br /> l 7a. Source, Process Equipment or Project: Capital Cost: S <br /> Ca . CostS Operating Cost:$ <br /> 8a. STATUS <br /> (� )t New Air Pollution Source <br /> ❑ Modification to Permitted Source (Control Equipment added, process change, etc.): <br /> ❑ Transfer of Ownership — Transferred from: <br /> ❑ Existing Source-not permitted (Include Date of Source Starr-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 /> q existing sources) <br /> 'I CI Requesting to iimit a source's Potential to Emit for Hazardous Air Pollutants only using Regulation No. 8 (for existing sources <br /> only) <br /> ❑ Other: <br /> II Projected Dates for Construction to: <br /> 8d. Projected Source Startup Date: <br /> 18b. Begin: Fool Sr. End: 7OZ:E;— 7ivJ) Gi 2dG <br /> 9. Enclose check to cover APEN FILING FEES. One APEN should be filed for each emission Fein <br /> NOTE: Additional processing fees must also be paid prior to penrrt issuance. <br /> j APENS ® $100.00 per APEN = S <br /> 10nEan*cturer <br /> SIGNATURE OFLEGALLYAUTHORMED PERSON(�VQT Vendor or I la. Date Signed: 11b. <br /> Phone:( ) <br /> Fax: <br /> 12. Tvpe Prin na a and o ctal rifle of person signing item 10. for Agency Use Only <br /> 14. DATE RECEIVED <br /> I <br /> i <br /> 13. Check appropriate box If you want: 15, PERMIT NUMBER <br /> a. O Copy of preliminary analysis conducted by Division <br /> b. O To review a draft of the permit prior to issuance <br /> :'1CPUF0RMS.9WCP APPN.9RA <br />