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State of Wisconsin FACILITY AND PROJECT IDENTIFICATION <br /> Department of Natural Resources AIR POLLUTION CONTROL PERMIT APPLICATION <br /> Section 144.391,Wisconsin Statutes <br /> Form 4500-1A Rev.12-86 <br /> 1. Facility Mailing Address: 2. Facility Location: <br /> Name Street or Route <br /> Street or Route City <br /> City,State,Zip Code County <br /> 3. Nature of Business,SIC Code,and Facility Identification Number <br /> 4. Parent Corporation: 6. Air Pollution Contact at Facility: <br /> Name Name <br /> Street Title <br /> City,State,Zip Code Telephone Number(Include Area Code and Extension) <br /> 6. Individual to whom the permit(s)should be issued— Name 7. Attach a plot plan of this facility which identifies the location of <br /> surrounding streets,facility property boundaries,the air <br /> pollution source(s)to be permitted and any stacks or vents <br /> Title exhausting the source(s),facility buildings and their respective <br /> exterior dimensions. Include any roads,parking lots or outdoor <br /> storage piles associated with the source(s)to be permitted.Use <br /> Telephone Number(Include Extension and Area Code) Form 4500-1F,Facility Plot Plan,or an equivalent format for <br /> this purpose. <br /> 8. Type of Air Permit Desired(check ✓ one) <br /> ❑ Construction of a new source ❑ Replacement of an existing source <br /> ❑ Modification of an existing source ❑ Existing source mandatory operation permit <br /> ❑ Reconstruction of an existing source ❑ Alteration of an existing permit <br /> ❑ Relocation of an existing source ❑ Elective operation permit <br /> 9. Briefly describe proposed project or existing source(s)to be permitted: <br /> 10. Anticipated Date of Construction <br /> 11. I,the undersigned,certify that the information submitted in this application is to the best of my knowledge both true and accurate. <br /> Signature Title Date Signed <br /> SEE INSTRUCTIONS ON REVERSE SIDE <br />