2012-01-13_REVISION - M1992058 ‎(5)‎

• Permit No: M1992058
• IBM Index Class Name: REVISION
• Doc Date: 1/13/2012
• Doc Name: Conversion Application
• From: Colorado Quarries, Inc.
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

Colorado Department of Public Health and Environment
Air Pollution Control Division
STATE OF COLORADO
Bill Ritter, Jr., Governor
Martha E. Rudolph, Executive Director
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr. S.
Denver, Colorado 80246 -1530
Phone [phone]
TDD Line (303) 691 -7700
Located in Glendale, Colorado
httpJ/www.cdphe.state.co.us
Laboratory Services Division
8100 Lowry Blvd.
Denver, Colorado 80230 -6928
(303) 692 -3090
AIR POLLUTION CONTROL DIVISION CONSTRUCTION PERMIT
FINAL APPROVAL SELF - CERTIFICATION FORM
SOURCE NAME: [Insert Company Name]
Colorado Quarries, Inc
FACILITY IDENTIFICATION NUMBER [Insert AIRS number]
(The AIRS number is found in the lower left comer of the permit)
043/0132/002
PERMIT NUMBER: [Insert Construction Permit Number] 09FRO0 7
•
-1.7 NIA
f`r ,
Colorado Department
of Public Health
and Environment
All information related to the Final Approval certification of the above referenced Initial Approval construction permit
must be certified by a responsible official as defined on the attached page. This certification means that each condition of
the Initial Approval permit has been reviewed and that the source is in compliance with all conditions of the permit. A
Final Approval permit will be issued only if all permit conditions are being met. The attached memo provides guidance on
what steps must be taken to certify compliance with various types of permit conditions. This signed certification document
must be packaged with the documents being submitted for the request for Final Approval of this permit. A separate
Certification along with the associated documentation is required for each individual Initial Approval permit. This
includes "dash numbered " permits (e.g. 96LA 199 -2).
I have reviewed the above paragraph, the attached document entitled "Guidance for Self- Certification", terms and
conditions of the initial approval permit referenced above, and the information being submitted for final approval
of this permit in its entirety. Based on information and belief formed after reasonable inquiry, I certify that the
source is in full compliance with each permit and condition of this initial approval permit, and the statements and
information contained in this submittal are true, accurate and complete.
Please note that the Colorado Statutes state that any person who knowingly, as defined in § 18- 1- 501(6), C.R.S.,
makes any false material statement, representation, or certification in this application is guilty of a misdemeanor
and may be punished in accordance with the provisions of § 25- 7122.1, C.R.S.
Nicole Krauth
Printed or Typed Name
Secretary /Treasurer
Title
Date Signed
K:IFORMSIFA forms: SELFCERT.DOC Revised 1 /06
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