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APPLICATION FOR CONSTRUCTION PERMIT OR PERMIT MODIFICATION <br />~Qravinuely rgfprror~ to sa E SSION PERIV~IT1 ' <br />This application must be filled out completely except for #14 and #15: otherwise, applicarion will be considered incompleu <br />SEE INSTRUCTIONS ON REVERSE SIDE. Mail completed application, APENs, and filiag fee to: <br />Colorado Dtpardsient of Public Htalth and Envlronnitnt <br />Alr Pollution Control Division <br />1900 Cherry Creek Dtivt South, MCD~BI <br />Denvtr Colorado 80246-1530 Tole host: 03 692-3150 <br /> <br />1. Permit tn. be issued to: Sc~ ~- ~ cQ T A ~ p--~ 9 a ~r t ~' <br />~- ~'~~ AY ~ ~~ Start: C 0 <br />2. Marling Address: ~ ~ 3 S <br />g <br />C..~ I ~,rat~p ~'r~f S1` Zi Code: ~oI/O <br />3a..lgent for Service (See No. 3 on reverse): <br />3b. Federal Tax Identt cation Number: <br /> <br />4a. General Nature ojBurtness: due ,q ~ <br />~9~}rrsafi-r Pry 4b. SIC Code: <br />Sa. Air Pollution Source Description: p aA <br />C e tar f~a.P t eU` fCre t.J Sb. Days per year source will <br />o erate: u~ <br />Souroce Locatton dddress (Include Location Map): /Yi i ~ I~ P~ T' <br />6a 6b. UTM Coordinates (in km) <br />. <br />~ 3 ~~s- F -t~r ~~-Ty R~ ~ ~9, C~ --- -H ---- -~ <br />(H tea To wtd R+nf0. fire diratiom ad dittmce from neuart town a intafaidon.) COU ~ 'fi <br /> <br />ESfIIVIATED COSTS: <br />1 Air Polat[on Control Procedural or Equipment <br />. <br />7a. Sour+ee, Process Equipment or Project: ~ 7b. Capital Cost: S <br />eratin Cost: S <br />~c <br />. Cost S . <br /> <br /> 8a. STATUS ~ ~ -~ <br />O New Air Pollution Source /hit-Xs fore.{ 1''~7,']ao~4r7f <br /> Modification to Permitted Source (Control Equipment added, process change, etc.): <br />O <br /> TY~ansfer of Ownership - IYnnsferred from: <br /> O Existing Source-not permitted (Include Date of Source Start-up): <br />^ Requesting to limit a source's Potential to E-nlt Jor criteria or Hazardous Air Pollutants using Regulation No. 3 (for new and <br /> txisdng sources) <br />O Requesting to limit a sowce's Potential to Emit for Hazardous dir Pollutants only using Regulation No. 8 (for existing sources <br /> on1Y) o <br />Othar: G~ LeCaT! oa 'f !~ ~Of rf 1~f <br /> <br /> jetded Darts Jor Construction to: <br />• <br />8d. ProJeeted Sourer Startup Date: <br /> 8b. Be 'n: 8c. End: <br /> <br /> 9. Enclose check to coverAPENFILING FEES. One.lPENshould bt filed for each emission point <br /> NOTE:.ldditional processing fees must also be paid prior to permit Issuance. <br /> APENS S100.00 a APEN ~ S <br /> 10. SIGNATURE OF LEG.lLLY.I UTHORIZED PERSON (~IQT Vendor or ! l a. Date Signed: l l b. <br />Phone:(71`~ )3`~z y2a7 <br /> EqurpmtntManyfacna~er) ~'~~, o ~ <br /> Fax: (719) ? 9 2 y2 y~ <br /> 12. Type or Print name and o,Qicia/ title of person signing item !0. for Agency Use Only <br />DATE RECEIVED <br />14 <br /> ~~ f ~ <br />~R a ~1SS'o . <br /> _ __~. Check appropriate bos li you want: 15. PERMIT NUMBER <br /> a. O Copy oJpreliminary analysis conducted by Division , <br /> b. D To review a draft o the permit rior to issuance <br />4~--..Jf _. __ <br />G'K.Tt1POaM3.9f A1CPJ-PPN.9RA <br />