AIR PERMIT APPLICATION COVER SHEET IDEM – Office of Air Quality – Permits Branch 100 N. Senate Avenue, MC 61-53 Room 1003 Indianapolis, IN 46204-2251 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 www.IN.gov/idem State Form 50639 (R4 / 1-10) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTES: The purpose of this cover sheet is to obtain the core information needed to process the air permit application. This cover sheet is required for all air permit applications submitted to IDEM, OAQ. Place this cover sheet on top of all subsequent forms and attachments that encompass your air permit application packet. PERMIT NUMBER: • Submit the completed air permit application packet, including all forms and attachments, to IDEM Air Permits Administration using the address in the upper right hand corner of this page. DATE APPLICATION WAS RECEIVED: • IDEM will send a bill to collect the filing fee and any other applicable fees. • Detailed instructions for this form are available on the Air Permit Application Forms website. • FOR OFFICE USE ONLY ____ ______ – __________ – ____________ 1. Tax ID Number: PART A: Purpose of Application Part A identifies the purpose of this air permit application. For the purposes of this form, the term “source” refers to the plant site as a whole and NOT to individual emissions units. 2. Source / Company Name: – 3. Plant ID: 4. Billing Address: City: 5. Permit Level: State: Exemption Registration SSOA ZIP Code: MSOP FESOP – TVOP PBR 6. Application Summary: Check all that apply. Multiple permit numbers may be assigned as needed based on the choices selected below. Initial Permit Renewal of Operating Permit Asphalt General Permit Review Request Revocation of Operating Permit Alternate Emission Factor Request Interim Approval Relocation of Portable Source Acid Deposition (Phase II) Site Closure Emission Reduction Credit Registry Transition (between permit levels) Administrative Amendment: From: To: Company Name Change Change of Responsible Official Correction to Non-Technical Information Notice Only Change Other (specify): Modification: New Emission Unit or Control Device Modified Emission Unit or Control Device New Applicable Permit Requirement Change to Applicability of a Permit Requirement Prevention of Significant Deterioration Emission Offset Minor Source Modification Significant Source Modification Minor Permit Modification MACT Preconstruction Review Significant Permit Modification Other (specify): 7. Is this an application for an initial construction and/or operating permit for a "Greenfield" Source? Yes No 8. Is this an application for construction of a new emissions unit at an Existing Source? Yes No Continued on Next Page Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department Of Environmental Management Office Of Air Quality State Form 50639 (R4 / 1-10) Air Permit Application Cover Sheet Page 2 of 2 PART B: Pre-Application Meeting Part B specifies whether a meeting was held or is being requested to discuss the permit application. 9. Was a meeting held between the company and IDEM prior to submitting this application to discuss the details of the project? No Yes: Date: 10. Would you like to schedule a meeting with IDEM management and your permit writer to discuss the details of this project? No Yes: Proposed Date for Meeting: PART C: Confidential Business Information Part C identifies permit applications that require special care to ensure that confidential business information is kept separate from the public file. Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in the Indiana Administrative Code (IAC). To ensure that your information remains confidential, refer to the IDEM, OAQ information regarding submittal of confidential business information. For more information on confidentiality for certain types of business information, please review IDEM’s Nonrule Policy Document Air-031-NPD regarding Emission Data. 11. Is any of the information contained within this application being claimed as Confidential Business Information? No Yes PART D: Certification Of Truth, Accuracy, and Completeness Part D is the official certification that the information contained within the air permit application packet is truthful, accurate, and complete. Any air permit application packet that we receive without a signed certification will be deemed incomplete and may result in denial of the permit. For a Part 70 Operating Permit (TVOP) or a Source Specific Operating Agreement (SSOA), a “responsible official” as defined in 326 IAC 2-7-1(34) must certify the air permit application. For all other applicants, this person is an “authorized Individual” as defined in 326 IAC 2-1.1-1(1). I certify under penalty of law that, based on information and belief formed after reasonable inquiry, the statements and information contained in this application are true, accurate, and complete. Name (typed) Title Signature Date American LegalNet, Inc. www.FormsWorkFlow.com