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APPLICATION FOR CONSTRUCTION PERMTT OR PERMIT MODIFICATION <br />Iprevlousiv referred bo as EMISSION PERMTTI <br />This application must be filled out completely except for #14 and #15: otherwise, application will be considered incomplete <br />SEE INSTRUCTTONS ON REVERSE SIDE. Mail completed application, APENs, and filing fee to: <br />Colorado Deparbaent ofPubUe Aealth and Environment <br />dir Pollution Conp»1 Division <br />4300 Chary Crcelt Dim South, .!1'CD-SS-BI <br />Denver Colorado 80146-1530 Tole hone: 03 692-3150 <br />1. Permit to be Issued to: / n <br />~ fi 1`'1 <br />SCh <br />' <br />F <br />Si <br />ry, ~ <br />5 <br />re Ct - <br />~P <br />2. MatlingAddress: ~~ 3 .~ ~2 ~'t'C Q rtv~ Co/orad(o ~lc'~t •Jf ~ State: CQ <br />Zi Code: ~ g /•~ <br />3a. Agent jor Service (See No. 3 on reverse): <br />3b. Federal Tax Identi cation Number: - <br />4s. General Nature of Business: ~} ^, ! <br />~r <br />C '~7 J <br />I 4b. SIC Code: <br />o OI L. <br />~ / Yt'(i' <br />~ <br />Sa .lit Pollution Source Destxipdon: ~ rOe r m i ~- <br />'t'e Sb. Days per year source will <br />~ <br />1 0 0 <br />o crate: <br />6a. Source Location dddress (Indude Location Map): 6b. UTMCoordinates ~n bn) <br />y 3 c~~ S E'~d~,T cot„,~~y R~~ ~ 2 9 --- -H ---- -~ <br />t yr T cad Ran6e, dive dnoaioot earl dipana Rom sweet town a iotareedon) COU : Et' de rT <br />7. ESTIMATED COSTS: Atr Pollation Control Procedures or Egnipment <br />h. Sour~ee, Process Equipment or Project: 7b. Capital Cast: S <br />. Cost S 7c. O t>rtttin Cost: S <br />8a. STATUS <br />D New Air Pollution Source <br />O Mod cation to Permitted Source (Control Equipment added, process change, etc.): <br />O Transfer of t`Jwnership -Transferred from: <br />O Existing Source- not permitted (Include Date ojSource Start-up): <br />D Requesting to limit a sota,ce's Potential to Emit jor criteria or Hasardous Air Pollutants using Regulation No. 3 (for new and <br />existing sources) <br />D Requesting to limit a source's Potential to Emit jor Hazardous dtr Pollutants only using Regubtion No. 8 (for existing sources <br />only) p <br />O Other: IJAnt C r r ?+, era., ~'~ - Re,Jew;,~ Pc r.-., .r <br />ProJeded Dales for Construtxion to: „ p _ ~~,, , <br />"'"" <br />~ <br />• / <br />8d. Projected Sou-+ce SttuYUp Date: <br />8b. Be 'n: 8c. End: ~-~- ` <br />9. Enclose c APENFILING FEES One.lPENshould be filed for each emission point <br />erptit issuance. <br />NOTE': Additional processing jeer must also be paid prior to p <br />s <br />APF.NS SI89:OQ APEN ~ S ll-- <br />10. SIGNATURE OF G Y.(UTHORILED PERSON (~(QT Vendor or <br />i <br />M <br />E 11a. Date Signed: 1 lb. <br />Phone:( Iq) 392 y2 <br />anujac ) ~ <br />qu <br />pment ~r~/ ~~ <br /> Fax: (71q) 392-YzyT <br />12. Type or Print name and o,~icia! title of person signing item /0. for Agency Use Only <br />~~ S ~ 14. DATE RECEIVED <br />` a. Check appropriate bo= if you want: l5. PERMIT NUMBER <br />a. O Copy ojprcliminary analysts conducted by Division <br />b. O To review a draft o the permit riot to issuance <br />L'k3ttPORMS.96A~CP,JIPPN.98A <br />