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ApPLICATiON FOR CONSTRUCTION PERMIT OR PERNIIT MODIFICATION <br />(orevioualy referred to as E1VI,ISSION PERMTII ' <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 fce to: <br />Colorado Department of Public Aealth and Environment <br />.!k Pollution Control Division <br />4300 Cherry Creek Drive South, APCD,SS-Bl <br />Denvtr Colorado 80246-1530 Tele hone: 03 692-3150 <br /> <br />1. Permit to be Issued to: <br /> <br />2. Mailing Address: ~ ~ 3 S De I 'fi q p n J( State: W <br />~o~ora ~ ~r,d51' (~~ Zt Code: ~~v <br />3a..lgent jot Service (see No. 3 on reverse): <br />3b. Federal Tax Identi cation Number: ~ <br /> <br />1 <br />4a. Genera/ Nature oJBusiness: ~9 .r Yo /!~ e ~~..! <br />I ( 4•}t rr1 <br />4b. SIC Code: <br />Sa. ,tit Pollution Source Description: ~ b fir C j~ro .rc <br />/e t ~) ? Sb. Days per year source will <br />3v~ <br />. o rate: <br />6a. Source Location Address (Include Location MapJ: ~l 3 G 1.S ~ / l~. T ~u ~.yt~r ~~ 6b. UTMH ordinates (in`brt) <br /> <br />(If wins Tow~uhip and Ran`e, afire dicabaa+ and dittanee from nareq wrvo or iateaecilon.) COU ~~bt r T <br /> <br />ESTIMATED COSTS: <br />7 Air Pollution Control Procedures or Equipment <br />. <br />7a, Source, Process Equipment or Project: 7b. Capital Cost. S <br />O eratin Cost: S <br />7c <br />~~ S . <br /> <br /> 8a. STATUS <br />O New Air Pollution Source " .5-'}.ti-~n,t a ~„~ ~ ~-~~..../~ <br />~ Modification to Permitted Source (Control Equipment added, process change, etc.): <br /> ^ T )~ansjer of Ownership -Transferred from: <br /> O Existing Source-not perntitted (Include Date of Sour~ee Start-up): <br />O Requesting to limit a source's Potential to Emit for criteria or Hazardous stir Pollutants using Regulation No. 3 (for new and <br /> existing sources) <br />O Requesting to limit a source's Potential to Emit jot Hazardous.llr Pollutants only using Regulation Na. 8 (for existing sources <br />' <br /> fe.e ,. <br />only) n ~ <br />Other: Gee .~+u~e ~ ca o,J V7, ~er>r„? ^Iv "/11u1~ 1 ?- `} CD2te~ a~U'/r!`s ~~+- <br /> Pro}eded Dates jot Construction to: <br />• <br />Sd. Pro}eeted Source Startup Date: <br /> 8b. Be 'n: 8c. End: <br /> 9. Enclose check to coverAPENFILING FEES. One.lPENshould be fled for each emission point <br /> NOTE:.ldditional processingfees must also be paid prior to permit issuance. <br /> APENS 5100.00 ADEN - S <br /> 10. SIGNATURE OF LEGALLYAUTHORIZED PERSON (~QZ Vendor or 11 a. Date Signed: 11 b. 3 S 2 ~ yz~ `) <br />Phone:(71Q ) <br /> Equipment Manufacturer d ar `'~ <br /> Fax: (~11) 39 z-Y?~i <br /> 12. Type or Print name and official title of person signing item 10. for Agency Use Only <br />14. DATE RECEIVED <br /> ~~f <br /> <br />' J. Check appropriate boz if yon want: 15. PERMIT NUMBER <br />a. O Copy ojpreliminary analysis conducted by Division , <br />b. O To review a draft of the permit prior to Issuance <br />L'K.TUPORM3.9aA~CP_NPPN.9sA <br />