MACT-01 PRE-CONSTRUCTION REVIEW 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/index.html State Form 51905 (R / 9-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTES: The purpose of this form is to provide a standardized way for sources to request MACT preconstruction approval per 40 CFR 63.5. FOR OFFICE USE ONLY This is a required form. PERMIT NUMBER: Detailed instructions for this form are available online at http://www.in.gov/idem/permits/air/apps/instructions/fed02instructions.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. Part A: General Information Part A is intended to identify the applicable MACT standard and affected source, and to determine whether 40 CFR Section 63.5 of the General Provisions is applicable to the affected source. 1. MACT Subpart Letter: MACT Source Category Name: 2. Affected Source(s): 3. Will the proposed construction be a major source of HAP emissions? Yes No Part B: Emissions Unit Information Part B is intended to identify those emissions units that are part of the affected source and will be constructed or reconstructed: 4. Unit ID 5. HAP Name or Type of HAP MACT Pre-Construction Review (MACT-01) 6. Quantity of HAP Emitted (specify units) Actual Emissions Potential To Emit Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY Air Permit Application MACT-01 Pre-Construction Review State Form 51905 (R / 9-04) Part C: Compliance Methods for New Affected Sources Part C is intended to identify the compliance method chosen for each new affected source. 7. Unit ID 8. Compliance Method Description 9. Control Efficiency (%) Part D: Compliance Methods for Reconstructed Affected Sources Part D is intended to identify the compliance method chosen for each reconstructed affected source. 10. Unit ID 11. Description of Current Compliance Method MACT Pre-Construction Review (MACT-01) 12. Description of Proposed Compliance Method 13. Control Efficiency (%) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com