AES-01 AIR EMISSION STATEMENT CERTIFICATION IDEM - Office of Air Quality Technical Support and Modeling Section - Mail Code 61-51 100 N. Senate Avenue Indianapolis, IN 46204-2251 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) http://www.emissions.IN.gov/ State Form 52052 (3-05) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT • This is a required form for each air emission statement as well as any modifications. • The certification supplied with a source’s permit may be used in lieu of this form • Instructions: “Responsible Official” has the same meaning as defined in 326 IAC 2-7-1 (34), and is usually designated in the General Information section of the permit. Part A: Contact Information Part A is intended to provide basic information about the company submitting an Air Emission Statement and information on the Air Emission Statement preparer in case there is a question about the report. 1. Company Name: 2. Source ID: 3. Mailing Address: City: State: ZIP Code: 4. Name of Emission Statement Preparer: 5. Title of Emission Statement Preparer: (optional): 6. Telephone Number: 7. Facsimile Number (optional): 8. Electronic Mail Address (optional): Part B: Emissions Summary Part B is intended to aid in the review of data and to collect information about billable hazardous air pollutants Emissions Statement Pollutants (Plant Wide) Tons Emitted Carbon Monoxide (CO) Lead (PB) Nitrogen Dioxide (NO2) Particulate Matter