Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Inital Notification Report Under Regulation 40 CFR Part 63 Subpart DDDDD Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
Loading PDF...
Tags: Inital Notification Report Under Regulation 40 CFR Part 63 Subpart DDDDD, 51956, Indiana Statewide, Department Of Enviromental Management
INITIAL NOTIFICATION REPORT UNDER REGULATION 40 CFR Part 63, Subpart DDDDD
State Form 51956 (10-04)
National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters and 40
CFR Part 63, Subpart A, §63.9(b) General Provisions.
This form is an example of how you can meet the requirement to submit an INITIAL NOTIFICATION REPORT under the following regulation: 40 CFR Part 63,
Subpart DDDDD—National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters and 40
CFR Part 63, Subpart A, §63.9(b) General Provisions.
This form is provided for your convenience. You are not required to use this form and may choose your own format to submit the required information.
You must submit an Initial Notification not later than March 12, 2005, or within 120 calendar days after your boiler or process heater becomes subject to the
National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters, whichever is later.
Please send one copy to each of the following agencies:
IDEM / Office of Air Quality
Compliance Branch
100 N. Senate Avenue, P.O. Box 6015
Indianapolis, Indiana 46206-6015
George Czerniak (AE-17J)
U.S. EPA, Region V
77 W. Jackson Blvd.
Chicago, Illinois 60604
Application for Approval of Construction or Reconstruction. If your boiler or process heater will be a new or reconstructed major affected source, you are
required by 40 CFR 63.5(d) to submit an Application for Approval of Construction or Reconstruction as soon as practicable before actual construction or
reconstruction begins. If you are also required to submit an Initial Notification (not all new or reconstructed units are required to submit Initial Notifications), you
may, as allowed under 40 CFR 63.9(b)(1)(iii), submit this Application for Approval of Construction or Reconstruction in lieu of an Initial Notification. If you
choose to take advantage of this option, you must submit the Application for Approval of Construction or Reconstruction according to the time frames
established in 40 CFR 63.5(d) instead of the time frames established for submitting Initial Notifications in 40 CFR 63.7545. Additionally, it is important to note
that all sources that are new or reconstructed major affected sources must meet the requirements of 40 CFR 63.9(b)(4) in addition to complying with the
requirements of 40 CFR 63.5(d).
This form is being submitted in accordance with 40 CFR 63.9(b) and as required by 40 CFR 63.7545.
If you own or operate an affected source, submit this report by MARCH 12, 2005, or WITHIN 120 CALENDAR DAYS after your boiler or process heater
becomes subject to the National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters,
whichever is later.
Print or type the following information for each facility for which you are making initial notification: (§63.9(b)(2)(i)-(ii))
SECTION 1
GENERAL INFORMATION
Operating Permit Number
Facility I.D. Number (IF AVAILABLE)
Responsible Official’s Name/Title
Street Address
City/State/ZIP code
Facility Name
Facility Street Address (If different than Responsible Official’s Street Address)
Facility Local Contact Name
Title
Phone
City/State/ZIP code
Check the box that applies. (§63.9(b)(2)(v))
My facility is a major source of Hazardous Air Pollutants (HAP)
My facility is an area source of HAP
NOTE: A major source is a source that emits or has the potential to emit 10 tons per year, or more, of any one HAP or 25 tons per year, or more, of
multiple HAP. All other sources are area sources. The major/area source determination is based on all HAP emission points inside the facility fence
line, not just inside the facility itself.
If you answered that your facility is an area source, the facility is not subject to this rule. Records of your applicability determination must be maintained
on site for 5 years. See 40 CFR 63.10(b)(3). If you answered that your facility is a major source for HAP emissions, complete the remaining questions.
American LegalNet, Inc.
www.FormsWorkflow.com
C. Indicate the relevant standard or other requirement that is the basis for this notification and the source’s compliance date: (§63.9(b)(2)(iii))
Basis for this notification (relevant standard or other requirement)
Anticipated Compliance Date (mm/dd/yy)
National Emission Standards for Hazardous Air Pollutants for Industrial,
Commercial, and Institutional Boilers and Process Heaters (40 CFR Part 63,
Subpart DDDDD)
SECTION 2
SOURCE DESCRIPTION
A.
Briefly describe the nature, size, design, and method of operation of the source. (§63.9(b)(2)(iv))
NOTE: If the same information requested above is contained in a title V permit application or permit, you may attach the relevant pages from that document
to this notification and reference those pages above.
B.
Identify the types of emission points within the affected source subject to the relevant standard and the types of hazardous air pollutants emitted.
(§63.9(b)(2)(iv))
Types of Emission Points
NOTE: Boilers and process heaters are typically served by chimneys or stacks for flue gas release and dispersion.
Types of HAP Emitted
Check the boxes indicating the principal types of HAP emitted by the affected source (i.e., boilers and process heaters). Check all that apply. For example,
coal and residual oil fired boilers or process heaters would typically emit all three types of HAP. Natural gas fired boilers or process heaters would typically
emit organic HAP.
Metal HAP (for example, arsenic, beryllium, cadmium, chromium, cobalt, lead, manganese, mercury, nickel, selenium)
Organic HAP (for example, acetaldehyde, benzene, formaldehyde, toluene, xylenes)
Acid gas HAP (for example, hydrogen chloride, hydrogen fluoride)
SECTION 3
SPECIFIC REQUIREMENTS
Section 63.7545(b)(2) requires you to include in this Initial Notification a signed statement indicating whether your affected source has a federally enforceable
permit that limits the annual capacity factor to less than or equal to 10 percent.
My facility has a federally enforceable permit that limits the annual capacity factor to less than or equal to 10 percent for the following boilers and
process heaters.
Use the facility identification number from section I.A.
My facility does not have federally enforceable permit that limits the annual capacity factor for any individual boiler or process heater to less than or
equal to 10 percent.
SECTION 4
CERTIFICATIONRY
I certify under penalty of law that, based on information and belief formed after reasonable inquiry, the statements and information contained or referenced in
this initial notification report are true, accurate, and complete.
Name of Responsible Official (Print or Type) Date
Title
(mm/dd/yy)
Signature of Responsible Official
Note: Responsible official is defined in 40 CFR §63.2, §70.2 and §71.2 and in EPA-approved State title V operating permits programs.
American LegalNet, Inc.
www.FormsWorkflow.com