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AIR POLLUTION CLERICAL PERMIT CHANGE ORDER <br /> Name eft Date 01 3 0Z <br /> Address T Prepared by <br /> Permit Renewal D ego <br /> CHANGE FOUND DURING INSPECTION <br /> [ ] Construction authorized by A/C# has been coin leted as authorized. <br /> Operation commenced on . (date - <br /> Bill per blue form # APF 51 completed during evaluation. <br /> Issue P/0 when fees received . <br /> Either [V] Change of Owner as of 06 iq D (date) <br /> or [ ] Change of Location as of (date) <br /> Bill for transfer fees an trans er permit to: <br /> D <br /> Name � V✓KOky oi � coa ^Y — <br /> Location <br /> Mailing Address <br /> _ CarflrhSPn <br /> [ ] Change in permit conditions as follows: <br /> continue on referse if necessaryf— <br /> [ ] Cancellation of billing <br /> Reason <br /> [ ] Cancellation of permit <br /> [ ] Closed but reopenable <br /> [ ] Closed and permanently removed <br /> [ ] Permit revoked <br /> [ ] Permit subject to variance <br /> [ ] Violation found. A/C needed. Hold billing and permit renewal until <br /> new A/C approved. <br /> [ ] Prorate fees and adjust anniversary date to <br /> Note: This form shall be completed for every source or permit unit in which a <br /> change of status has occurred since the last inspection. , <br /> Filinq Code:1 1W 1, <br /> EH 01 50 10/81 500 <br />