Laserfiche WebLink
APPLICATION FOR AIROLLUTION EMISSION PERMIT ORIPERMiT MODIFICATION <br /> 1 <br /> This application must be filled out completely except for #14 and #15: otherwise, application will be considered incomplete - SEE <br /> INSTRUCTIONS ON REVERSE SIDE. Mail completed application APENs and filing fee to: <br /> Colorado Department of Health <br /> APCD-SS-BI <br /> 4300 Cherry Creek Drive South <br /> Denver, Colorado 80222-1530 Telephone: (303)692-3150 <br /> 1. Permit to be issued to: <br /> 2. Mailing Address: i.3� r ��Ia/1YZ�SQ_ State: c t/ <br /> A C) � <br /> Zip Code:91 <br /> 3a. Agent for Service (See No. 3 on reverse): <br /> 3b. Federal Tar Idcnrfication Number: <br /> 4a. General Nature of Business: 4b. SIC Code: <br /> Sa. Air Pollution Source Description: 5b. Days per year source will <br /> operate: <br /> 6a. Source Location Address (include Location Map): 6b. UTM Coordinates (in kin) <br /> H V <br /> Of u im Ta Wp W Ruse,pw d:mni"W dictum fr County: <br /> 7. ESTIMATED COSTS: Air Pollution Control Procedures or Equipment <br /> 7a. Source, Process Equipment or Project: 7b. Capital Cost: $ <br /> Cap. Cost $ 7e. Operating Cost: $ <br /> 8a. STATUS <br /> ❑ 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 Start-up): <br /> ❑ Ocher: <br /> Projected Dales for Construction to: Projected Source Startup Date: <br /> 8b. Begin: 8c. Fnd: Id. <br /> 9. Enclose check to cover APEN FILING FEES. One APEN should be filed for each emission point <br /> NOTE: Additional processing fees must also be paid prior to permit issuance. <br /> APENS ® $100.00 per APEN = $ <br /> 10. SIGNATURE OF LEGALLY AUTHORIZED PERSON (NOT Vendor or 1 la. Date Signed: I lb. Telephone No.: <br /> Equipment Manufacturer) ( l <br /> 12. Type or Print name and official title of person signing item 10. ` J <br /> Agency Use Only <br /> 14. DATE RECEIVED: <br /> 13. Check appropriate box if you want: <br /> a. ❑ Copy of preliminary analysis conducted by Division <br /> b. ❑ To review a draft of the permit prior to issuance? 15. PERMIT NUMBER <br /> Naa: Qeclin{eider Ian iaN iwW,b La+usd tea ud/ar pner'vy,imc.Sa Rcwis. ' <br />