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APPLICATION FOR CONSTRUCTION PERMIT OR PERMIT MODIFICATION <br />SEE INSTRUCTIONS ON REVERSE SIDE. Mail completed application,APENs,andfilingfeeto: <br /> Colorado Department of Public Health and Environment <br /> Air Pollution Control Division <br /> 4300 Cherry Creek Drive South,APCDSS-Bl <br /> Denver, Colorado 80246-1530 Tele hone: 303 692-3150 <br />1. Permit to be issued to: Weld County Public Works <br />2. Mailing Address: P, 0. Box 758 <br /> Greeley CO 80632 <br />3. Agent for Service: Greg Nelson <br />4. General Nature of Business: County government -crush and stockpile material for <br /> county road maintenance and construction <br />S.- Air Pollution Source Description: gravel nit <br /> SIC code (if known) 1442 Is this a Portable Unit? Yes / No <br />6. Source Location Address (Include Location Map) If portable, include the initial location and home base location <br /> 39434 WCR 115, New Raymer <br /> Home base -Weld County Public Works, 1111 H Street, Greeley, CO <br /> <br />7. STATUS <br />® New or Previously Unreported Source <br />^ Requesting Modification of Permitted Source (Control Equipment added, process change, etc.): <br />^ Change in Emissions, Throughputs, or Equipment <br />^ Transfer of Ownership - Include an Administrative Amendment Form <br />^ Requesting to limit a source's Potential to Emit (Synthetic Minor) for criteria or Hazardous Air Pollutanu using Regulation <br /> No. 3 (for new and existing sources) <br />^ Requesting to limit a source's Potential to Emit for Hazardous Air Pollutants only using Regulation No. 8 (for existing <br /> sources only) <br />^ Other: <br />9. Projected or Existing Source Startup Date: 92005 <br />10. Enclose check to ver APEN FILING FEES. One ADEN should be filed for each emission point/or group of points <br /> NOTE: Additi processing fees must also be paid prior to permit issuance. <br /> l <br />~l <br /> as <br />v, <br /> tgnature Of egally Authorized Person (NOT Vendor or Equipment Manufacturer) Date Signed <br /> Greg Nelson, Mining Supervisor Phone:(S70},~D4-6496 <br /> Type or Print Name And Official Title Of Petson Signing Above Fax: (, f74J3b~1 -6 U 97 <br />ll. Check appropriate box if you want: For Division Use Only: <br /> ^ Copy of preliminary analysis conducted by Division Pertnit Number. <br /> ^ To review a draft of the permit prior to issuance AIRS ID: . <br />Norc: Chttldng cisher item could rcsuh in incmaned feu md/or processing time. Sce Rcvvse. <br />Revised July 2001 http~//www cdohestate.co.us/an/stationary asn <br />