CD-04 – Compliance Schedule and Certification – INSTRUCTIONS Microsoft Word version of CD-04 Adobe PDF version of CD-04 The purpose of CD-04 (state form 51864) is to provide a schedule of for compliance certification submittals, a certification of the source’s compliance status with all applicable requirements, and a compliance schedule that details the measures a source will use to address non-compliance. This form is completed once per application (not once for each emissions unit) with respect to all applicable requirements at the source. CD-04 is a required form for all Title V permit applications submitted to IDEM, OAQ. For the purposes of this form, the term “source” refers to the plant as a whole and NOT to the individual emissions units. NOTE: The Compliance Determination forms, CD-01 through CD-04, are required for a "complete" application under the Part 70 Permitting Program (Title V) per 326 IAC 2-7-4(c), paragraphs (4), (11), (12), and (14). These forms must be completed for each initial Title V permit application as well as each modification and every renewal. If you have any questions, contact the Air Permit Reviewer of the Day (PROD) at (317) 233-0178 or 1-800-451-6027 extension 3-0178 (toll free call within Indiana). Part A: Source Identification and Compliance Schedule Part A identifies the permitted source and the permit term compliance certification schedule. 1. Source Name: Provide the legal name of the company that will be used to conduct official business with this source. 2. Source ID: The source identification (ID) number consists of a three (3) digit county code and a five (5) digit source code separated by a dash (-). Sources that have been previously permitted with the OAQ should have received a source ID from our office. If you are planning to construct an entirely new source, you will not yet have a source ID, so you will need to put the words “Not Applicable” on this line. If you think you have a source ID, but you are not sure, contact the Air Permit Reviewer of the Day (PROD) at (317) 233-0178 or 1-800-451-6027 extension 3-0178 (toll free call within Indiana). 3. Permit Term Compliance Certification Schedule: Provide the date of first certification submittal and the frequency of future submittals. Part B: Risk Management Plan Part B indicates whether sources subject to section 112(r), Accidental Release Prevention, are complying with the requirement to submit a Risk Management Plan (RMP). A Risk Management Plan (RMP) is required under Section 112(r) of the Clean Air Act (CAA) for certain sources that have a Section 112(r) listed chemical above the threshold amount in a process. These sources must comply with the Chemical Accident Prevention Provisions in 40 CFR 68. These provisions include the requirement to have a Risk Management Program and the requirement to submit an RMP to the United States Environmental Protection Agency (U.S. EPA) pursuant to 40 CFR 68 Subpart G. 4. Statement of Applicability / Non-Applicability: Indicate whether the source is subject to Section 112(r) and the requirement to submit an RMP. RMP Submitted: Indicate when the RMP was submitted to each of the following agencies. 5. Agency Name: The RMP must be submitted to each of the listed agencies, including any local agency near the permitted source. Identify the name of the local agency in the space provided, or if there is no Local Agency that would need to receive the RMP, put “NA” next to the line for the Local Agency. 6. Date Submitted: Specify the date on which you submitted the RMP to each agency. If the RMP for IDEM is attached to this application, please write “attached” in the Date Submitted column. 7. Expected Submittal Date: If the RMP has not yet been submitted to any of the listed agencies, indicate the date when the RMP will be mailed to that agency. American LegalNet, Inc. www.FormsWorkflow.com 8. EPA Facility Identifier: The EPA Facility Identifier is a twelve (12) digit number that the EPA assigns to a source once they have determined an RMP is complete. The EPA Facility Identifier will be four (4) digits, a space, four (4) more digits, another space, and then four (4) more digits. If you are unsure of your EPA Facility Identifier, you can look it up on the EPA Chemical Emergency Preparedness and Prevention Office Website Part C: Certification of Source Compliance Status Part C states whether the source is or is not in full compliance with all applicable requirements and to identify corrective actions to be taken in cases of noncompliance. 9. Check the Most Accurate Statement: Choose the statement that most accurately describes the compliance status of the source with all applicable requirements. 10. Unit ID: Provide the identification number for each emissions unit. The identification numbers listed on this form should correspond to the emissions unit identified on the Plant Layout diagram and Process Flow diagram. 11. Applicable Requirement: Identify the applicable requirement for which compliance is not being met. 12. Corrective Action: Summarize the schedule of measures leading to compliance with all requirements including remedial measures. Reference any orders, decrees or other judgements that establish or more fully describe the compliance schedule. 13. Deadline: Specify deadlines for milestone events (e.g. contract award date, start dates for construction or installation, completion of operator training, etc.). 14. Progress Reports: Provide a schedule for the submission of progress reports for the corrective actions you are taking to bring the source back into compliance with all requirements. The schedule must include a starting date and the schedule for submission of reports on a regular basis. The frequency of submittals must be at least semi-annually (every 6 months).Refer to appropriate documents that establish or more fully describe the submission schedule. 15. Signature of Responsible Official: The “responsible official” as defined in 326 IAC 2-7-1(34) must review the contents of compliance certification, and certify that the information is truthful, accurate, and complete with respect to the source’s current operations by placing a check on the box next to the certification statement. Below the certification statement in the spaces provided, the “responsible official” must provide their legal name, their title (with respect to the source), their signature, and then provide the date on which they certified the compliance information. ***SUBMISSION OF CONFIDENTIAL RECORDS*** All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality. Claim of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your confidential information becoming a public record, available for public inspection. 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. American LegalNet, Inc. www.FormsWorkflow.com CD-04 – COMPLIANCE SCHEDULE AND CERTIFICATION State Form 51864 (R / 9-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTES: • • • • • The purpose of CD-04 is to provide a schedule of for compliance certification submittals, a certification of the source’s compliance status with all applicable requirements, and a compliance schedule that details the measures a source will use to address non-compliance. This form is completed once per application (not once for each emissions unit) with respect to all applicable requirements at the source. This is required form for each initial Title V permit application as well as each modification and every renewal. Detailed instructions for this form are available online at http://www.in.gov/idem/permits/air/apps/instructions/cd04instructions.html. All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality. Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your information becoming a public record, available for any one to inspect and photocopy. IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue Indianapolis, IN 46204 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 http://www.IN.gov/idem/permits/air FOR OFFICE USE ONLY PERMIT NUMBER: ____ ______ – _________ – ____________ PART A: Source Identification and Compliance Schedule Part A is intended to identify the permitted source and to identify the permit term compliance certification schedule. 1. Source Name: 2. Source ID: __ __ __ - __ __ __ _ __ 3. Permit Term Compliance Certification Schedule Date of first certification submittal: Frequency of future submittals: PART B: Risk Management Plan Part B is intended to indicate whether sources subject to section 112(r), Accidental Release Prevention, are complying with the requirement to submit a Risk Management Plan (RMP). 4. Statement of Applicability / Non-Applicability: Indicate whether the source is subject to Section 112(r) and the requirement to submit and RMP. Source is subject to Section 112(r) and a Risk Management Plan (RMP) is required. Source is not subject to Section 112(r) and a Risk Management Plan (RMP) is not required. RMP Submittal Information: Indicate when the RMP was submitted to each of the following agencies. If the RMP has not yet been submitted to any of the listed agencies, indicate the date when the RMP will be mailed to that agency. If the RMP for IDEM is attached to this application, please write “attached” in the Date Submitted column. 5. Agency Name 6. Date Submitted 7. Expected Submittal Date Chemical Safety and Hazard Investigation Board (CSHIB) United States Environmental Protection Agency (U.S. EPA) Indiana Department of Environmental Management (IDEM) Local Agency responsible for permitting: 8. EPA Facility Identifier: ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___ Continued on next page Compliance Schedule and Certification (CD-04) American LegalNet, Inc. Page 1 of 2 www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 51864 (R / 9-04) Compliance Certification FORM CD-04 PART C: Certification of Source Compliance Status Part C is intended to state whether the source is or is not in full compliance with all applicable requirements and to identify corrective actions to be taken in cases of noncompliance. 9. Check the Most Accurate Statement. The source described in this air pollution control permit application is fully in compliance with all applicable requirements and will continue to comply with those requirements. FORM CD-01 includes new requirements that apply or will apply to the emissions unit during the term of the permit. The source will meet such requirements on a timely basis. The source described in this air pollution control permit application is fully in compliance with all applicable requirements, except for the emissions unit(s) listed below. Compliance will be achieved according to the schedule identified below. 10. Unit ID 11. Applicable Requirement 12. Corrective Action 13. Deadline 14. Progress Reports Start Date Frequency 15. Signature of Responsible Official I certify that, based on information and belief formed after reasonable inquiry, the statements and information presented are true, accurate and complete. _________________________________________ Name (typed) ____________________________________________ Title _________________________________________ Signature ____________________________________________ Date Compliance Schedule and Certification (CD-04) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com