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San Joaquin Valley Air Pollution Control District <br /> www.valleyair.org <br /> Permit Application For: <br /> AUTHORITY TO CONSTRUCT(ATC) -New Emission Unit <br /> AUTHORITY TO CONSTRUCT(ATC) -Modification Of Emission Unit With Valid PTO/Valid ATC <br /> AUTHORITY TO CONSTRUCT(ATC) -Renewal of Valid Authority to Construct <br /> Ej PERMIT TO OPERATE(PTO) -Existing Emission Unit Now Requiring a Permit to Operate <br /> 1. PERMIT TO BE ISSUED TO: <br /> 2. MAILING ADDRESS- <br /> STREET/P.O.BOX: Z00p70 qQ Q?kS bl')Ve , e <br /> 9-DIGIT p �/ <br /> CITY: 6 PQlww. STATE: ZIP CODE: !SO 33 <br /> 3. LOCATION WHERE THEEQUIPMENT WILL BE OPERATED: WITHIN 1,000 F A <br /> STREET: See jr V G3� 2cor ft&c,- CITY: SCHOOL? YES ONO <br /> S.I.C.CODE(S)OF FACILITY <br /> /4 SECTION TOWNStIIP RANGE (Ifknown): <br /> 4. GENERAL NATURE OF BUSINESS: &&mer eenv INSTALL DAIE� Q <br /> 5. I=V PERMIT HOLDERS ONLY. Do you request a COC(EPA Review)prior to receiving your ATC(Ifyes, Yt1E�SJ/ NO <br /> please complete and attach a Compliance Certification form(ITFORM--005)? <br /> 6. DESCRIPTION OF EQUIPMENT OR MODIFICATION FOR WHICH APPLICATION IS MADE(include Permit#'s if known,and use <br /> additional sheets if necessary) <br /> fie_ <br /> 7. PERMIT REVIEW PERIOD: Do you request a three-or ten-day period to review the draft Authority to Construct 3-day review <br /> permit?Please note that checking"YES"will delay issuance of your final permit by a corresponding number of W 10-day review <br /> working days. See instructions for more information on this review process. o review requested <br /> 8. HAVE YOU EVER APPLIED FOR AN ATC OR YES ONO Optional Section <br /> PTO IN THE PAST? If es ATC/PTO#: 11.CHECK WHETHER YOU ARE A SPA / <br /> Y PARTICIPANT IN EITHER OF <br /> 9. HAVE ALL NECESSARY LAND-USE THESE VOLUNTARY PROGRAMS: <br /> AUTHORIZATIONS BEEN OBTAINED? S NO "SPARE THE AIR" 1AIR <br /> (If"No"is checked,please attach explanation) es rjNo <br /> Send info <br /> 10.IS THIS APPLICATION SUBMITTED AS THE YES O "INSPECT' 1fSP <br /> RESULT OF EITHER A NOTICE OF VIOLATION If yes,NOVINTC#: Yes MNo E3Send info <br /> OR A NOTICE TO COMPLY? <br /> 12. TYPE R-PRINT PAME.OF APPLICANT: TITLE OF APPLICANT: <br /> siipf awl !`Ply <br /> 13. SIVF F PLICANT: DATE: PHONE#: ) 6 7,F- ;ofl <br /> FAX #: f wb)I0 <br /> E-MAIL: /yJ hC�rSC y <br /> FOR C U E ONLY: <br /> DATE ST FILING FEE <br /> RECEIVED: $ CHECK#: <br /> DATE PAID: <br /> PROJECT#: FACILITY ID: <br /> Northern Regional Office*4230 Kiernan Avenue,Suite 130*Modesto, California 95356-9321 *(209)557-6400*FAX(209)557-6475 <br /> Central Regional Office* 1990 East Gettysburg Avenue*Fresno, California 93726-0244*(559)230-5900*FAX(559)230-6061 <br /> Southern Regional Office*2700 M Street, Suite 275*Bakersfield,California 93301-2370*(661)326-6900*FAX(661)326-6985 <br /> Rev:Jawary 28,2005 <br />