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Air Pollution Control Division Construction Permit Application PLEASE READ /NSTRUCT/ONS ON REVERSE SIDS 1. Permit to be issued to: C, v L 2. Mailing Address: , Q, ( x ~S /3S U SZ 3Z / 3. General Nature of Business: ~yf"T~~(~wr ~lfT~/e/~-S --~ ~~/~Gj~(~ SIC code (if Imownj `~ 7~ / 442 4. Air Pollution Source Description: S ~~~ ~~_P/.r' (Lis[ permit numbers if existing source, attach additional pages if needed) Is this a Portable Unis? yeS No 5. Source Location Address (Include Location Map) If portable, include the initial location and home base Iota ' ~E I ~ ~l F 6. Reason for Application: (Check all that apply] New or Previously Unreported Source Administrative Permit Amendments Modification of Existing Source ^ Transfer of Ownership (Complete Section 9 & 10 below) ^ Request for Synthetic Minor Permit ^ Company Name Change (Complete Section 9 below) ^ Other: ^ Ctther: 7. Projected Startup Date: - ~" ~-~~-~2 Signature a{ly Authorized Person of Company listed inn Section I /Date Signed b ~ r / _/~/ Phone: 1383 -'~eSOd Type or Print Name and Official Title of Person Signing Above Fax: '--~ 8. Che appropriate box if you want: Copy of preliminary analysis conducted by Division To review a draft of the permit prior [o issuance ese see6ons are to be completed only if a company name change or transfer ojownership has occurred 9. Pe reviously issued to: l0. Transfer of Owner formation Effective Date of Permit T As responsible party for the emission source ' ted above, I certify that the business associated with [his source has been sold, and agree to transfer the permit to said party. Signature of Legally Authorized Person of Company listed in Section 9 Date Signed P Type or Print Name and Official Title of Person Signing Above Fax: Mail completed application, APENs, and filing fee to: Colorado Department of Public Health and Environment htto'//www.cdohestate.co.us/ap/stationary.html Air Pollution Control Division Phone: (303) 692-3150