GSD-01 – Basic Source Level Information – INSTRUCTIONS Microsoft Word version of GSD-01 Adobe PDF version of GSD-01 The purpose of GSD-01 (State Form 50640) is to provide essential information about the entire source of air pollutant emissions. GSD-01 is a required form for all air 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. 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 / Company Location Information Part A gathers information about the location of the source of air pollutant emissions. The questions in this section refer to the plant site, or “source”, of air emissions. 1. Source / Company Name: Provide the legal name of the company or plant that will be used to conduct official business with this source. 2. Plant ID: The plant 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 plant ID from our office. If you are planning to construct an entirely new source, you will not yet have a plant ID, so you will need to put the words “Not Applicable” on this line. If you think you have a plant ID, but you are not sure, contact the air permit reviewer of the day at (317) 233-0178 or 1-800-451-6027 extension 3-0178 (toll free call within Indiana). 3. Location Address: Provide the address where the source is located. This may or may not be the mailing address. For new source construction, provide the address of the site where the source will be located. 4. County Name: Provide the name of the county where the source is located. For new source construction, provide the county where the source will be located. 5. Township Name: Provide the name of the township where the source is located. For new source construction, provide the township where the source will be located. 6. Geographic Coordinates: Provide the latitude and longitude of the source. This information may be obtained from United States Geological Survey (USGS) maps. 7. Universal Transversal Mercator Coordinates (if known): Universal Transversal Mercator (UTM) coordinates describe the exact location of the source. They can be obtained from the USGS or the Indiana Department of Natural Resources (IN-DNR). Zone 16 is a fixed UTM number for Indiana. 8. Adjacent States: Is this source located within 50 miles of an adjacent state? Indicate whether or not the source is located within fifty (50) miles of the border of a state adjacent to Indiana. If yes, identify the state(s) whose border is within 50 miles of this source. [Illinois (IL), Michigan (MI), Ohio (OH), or Kentucky (KY)]. 9. Attainment Area Designation: Is this source located within a non-attainment area for any one of the criteria air pollutants? Indicate whether the source is located within a non-attainment area for any one of the criteria air pollutants. If yes, identify the pollutants for which this source is considered to be in a non-attainment area. [Ozone (O3) – regulated as volatile organic compounds (VOC), nitrogen dioxide (NO2) – regulated as nitrogen oxides (NOx), sulfur dioxide (SO2), particulate matter (PM), particulate matter less than 10 microns (PM10), particulate matter less than 2.5 microns (PM2.5), carbon monoxide (CO), and lead (Pb)]. For additional information regarding Indiana Nonattainment areas, please refer to 40 CFR 81.315 or the IDEM, OAQ webpage regarding Attainment of Air Quality Standards. 10. Portable / Stationary: Is this a portable or stationary source? Indicate whether the source is “portable” or “stationary” by checking the appropriate box. A portable source is defined in 326 IAC 2-1.1-1(15), and a new portable source is defined in 326 IAC 2-1.1-1(9). The American LegalNet, Inc. www.FormsWorkflow.com permitting rules concerning portable sources are codified in 326 IAC 2-14. A stationary source is defined in 326 IAC 2-3-1(aa). Part B: Source Summary Part B gathers information about the current and recent status of the source. 11. Internet Address: (Optional) Provide the Internet address (website) for the source. 12. Company Name History: Has this source operated under any other name(s)? Indicate whether the source has recently changed its legal name. For the purposes of this question, “recently” means within the last twelve (12) months, or since this source last applied for an air permit or modification. If the legal name of the company has changed, complete Part I, Company Name History, to provide more details on the previous names used and to specify the name that should be used on official documents issued by IDEM. OAQ. 13. Portable Source Location History: Will the location of the portable source be changing in the near future? This question only applies to portable sources. The permitting rules concerning portable sources are codified in 326 IAC 2-14. Stationary sources cannot “relocate”; therefore, any stationary source that moves to a new location is considered a new source and must comply with the applicable new source construction rules in 326 IAC 2-5.1. Indicate whether the portable source will be moving to a new location. If applicable, complete Part J, Portable Source Location History, to provide all previous locations. If applicable, complete Part K, Request to Change Location of Portable Source, to provide the current and future locations. 14. Existing Approvals: Have any exemptions, registrations, or permits been issued to this source? Check “No” if this application is for an initial air permit. Check “Yes” if the source has applied for and received approval for any other air construction or operating permits in Indiana. List these permits and their corresponding emissions units in Part M: Existing Approvals. If you do not know whether an air permit has been previously issued for your source, contact the air permit reviewer of the day at (317) 233-0178 or 1-800-451-6027 extension 3-0178 (toll free call within Indiana). 15. Unpermitted Emissions Units: Does this source have any unpermitted emissions units? Check “No” if there are no existing unpermitted emissions units at the source and no new construction has taken place subsequent to last issued air permit for this source; otherwise check “Yes”. This question also applies to insignificant and/or trivial emissions units that do not require pre-construction approval. List these unpermitted emissions units in Part N: Unpermitted Emissions Units. 16. New Source Review: Is this source proposing to construct or modify any emissions units? Check “No” if the application is for a permit renewal, and no additional emissions units are to be constructed or modified at this time. Check “Yes” if this application is for an initial air permit or for a modification to an existing source. List these new or modified emissions units in Part O: New or Modified Emissions Units. 17. Risk Management Plan: Has this source submitted a Risk Management Plan? 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 (US EPA) pursuant to 40 CFR 68 Subpart G. Check "Not Required" if a RMP is not required for your source. Check "No" if a RMP is required for the source but has not yet been submitted to EPA. Check "Yes" if your source has submitted a RMP to EPA and provide date on which you submitted the RMP and the EPA Facility Identifier that was assigned to your source. 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: Source Contact Information Part C identifies the Source Contact. IDEM will send the original, signed permit decision to the person identified in this section. This person MUST be an employee of the permitted source. This person should be reasonably available during the review of the permit application to answer questions and provide additional information about the application as needed. American LegalNet, Inc. www.FormsWorkflow.com 18. Name of Source Contact Person: You must provide a contact person at the source, even if a consulting firm is preparing the application. The contact person cannot be the consultant. 19. Title: (Optional) Provide the title or basic job description for the source contact person. 20. Mailing Address: Provide the mailing address for the source. If the mailing address is the same as the location address, put the words “Same As Location” on this line. 21. Electronic Mail Address: (Optional) Provide the electronic mail (email) address for the source (or for the contact person at the source). 22. Telephone Number: Provide the telephone number for the source (or for the contact person at the source). 23. Facsimile Number: (Optional) Provide the facsimile number for the source. Part D: Authorized Individual / Responsible Official Information Part D identifies the Authorized Individual or Responsible Official. This person is responsible for the truth, accuracy, and completeness of this permit application and must sign a statement to this effect on the application cover sheet and on the compliance certification (for Part 70 sources). If this person is different from the source contact, a copy of the permit decision will also be sent to this person. 24. Name of Authorized Individual or Responsible Official: Provide the name of the person who will provide certification for the application, any required reports, and compliance certifications. For a registration, new construction project (NSR – New Source Review), MSOP, or FESOP, this person is the "authorized individual". An “authorized individual” is defined in 326 IAC 2-1.1-1(1). For a TVOP or a SSOA, this person is the "responsible official". A "responsible official" is defined in 326 IAC 2-7-1(34). 25. Title: Provide the title of the authorized individual or responsible official. 26. Mailing Address: Provide the mailing address for the source (or for the authorized individual/responsible official for the source). 27. Telephone Number: Provide the telephone number for the source (or for the authorized individual/responsible official for the source). 28. Facsimile Number: (Optional) Provide the facsimile number for the source (or for the authorized individual/responsible official for the source). 29. Request to Change the Authorized Individual or Responsible Official: Is the source officially requesting to change the person designated as the Authorized Individual or Responsible Official in the official documents issued by IDEM, OAQ? Check “No” if the applicant does not wish to make an official change to the person identified as authorized individual or responsible official. Answering “Yes” to this question will trigger processing of an official request to change the company’s authorized individual or responsible official, and the applicant must provide the new name of the authorized individual or responsible official as it should be written on all official documents. Although IDEM needs to have a name for mailing official documents, the permit may list the title of the Authorized Individual or Responsible Official in lieu of a specific name. Part E: Owner Information Part E identifies the owner of the source. 30. Company Name of Owner: Provide the legal name of the company that owns the source. If the “Owner” company is under the same name as the source then put the words “Same As Source” on this line. If the “Owner” company also has the same contact information as the source, proceed to item #33. 31. Name of Owner Contact Person: Provide the name of a representative of the company that owns the source that shall serve as the official contact person for business with the “Owner” company. American LegalNet, Inc. www.FormsWorkflow.com 32. Mailing Address: Provide the mailing address for the “Owner” company. 33. Telephone Number: Provide the telephone number for the “Owner” company (or for the “Owner” contact person). 34. Facsimile Number: (Optional) Provide the facsimile number for the “Owner” company. 35. Operator: Does the “Owner” company also operate the source to which this application applies? Check “No” if a company, other than the owner, operates this source, and provide information on the operator in the next section, Part F: Operator Information. If the operating company and the owner company are the same, check “Yes”, enter “Same as Owner” on this line, and proceed to Part G: Agent Information. Part F: Operator Information Part F identifies the operator of the source. 36. Company Name of Operator: Provide the legal name of the company that operates the source. If the “Operator” company is under the same name as the source then put the words “Same As Source” on this line. If the “Operator” company also has the same contact information as the source, proceed to the next section, Part G: Agent Information. If the “Operator” company is under the same name as the owner then put the words “Same As Owner” on this line. If the “Operator” company also has the same contact information as the owner, proceed to the next section, Part G: Agent Information. 37. Name of Operator Contact Person: Provide a contact person for the “Operator” company. This contact person may also be the source contact, but cannot be a consultant. 38. Mailing Address: Provide the mailing address for the “Operator” company. 39. Telephone Number: Provide the telephone number for the “Operator” company (or for the “Operator” contact person). 40. Facsimile Number: (Optional) Provide the facsimile number for the “Operator” company. Part G: Agent Information (If Applicable) Part G identifies the entity or firm that will represent this source. This may be a consultant or a legal firm. 41. Company Name of Agent: Provide the legal name of the entity or firm representing this source. If no such representation exists, then put the words “Not Applicable” on this line and proceed to the next section, Part H: Local Library Information. 42. Type of Agent: Specify whether the agent is and environmental consultant, an attorney, or other entity. 43. Name of Agent Contact Person: Provide a contact person for the agent. 44. Mailing Address: Provide the mailing address for the agent. 45. Electronic Mail Address: (Optional) Provide the electronic mail (email) address for the agent (or for the agent contact person). 46. Telephone Number: Provide the telephone number for the agent (or for the agent contact person). 47. Facsimile Number: (Optional) Provide the facsimile number for the agent. 48. Request for Follow-up: Does the “Agent” wish to receive a copy of the preliminary findings during the public notice period (if applicable) and a copy of the final determination? Check “No” if the “Agent” does not wish to receive a copy of the preliminary findings or the final determination. If the American LegalNet, Inc. www.FormsWorkflow.com “Agent” is assisting the company in following the progress of this application, check “Yes”. Answering “Yes” to this question will guarantee that the “Agent” receives a copy of the draft and final permit. If the “Agent” wishes to receive copies of other correspondence between the company and IDEM, OAQ, the “Agent will need to coordinate retrieval of this information with the company contact. Please note that inclusion of an electronic email address will make it easier for IDEM, OAQ to contact the “Agent”, but does not guarantee that the permit reviewer will regularly correspond with the “Agent” via electronic mail. Part H: Local Library Information Part H identifies the local library that is located nearest to the source in the same county. 49. Date permit application records were (or will be) placed in the library: Provide the date on which you filed your permit application packet with the local library. If you have not yet submitted a copy of your application packet to the local library, provide the date on which you intend to place these materials in the library. NOTE: The public notification laws require that each applicant place a copy of their complete permit application packet at a local public library within ten (10) days after submitting the permit application to IDEM, OAQ. Any additional information that is submitted to IDEM, OAQ regarding this permit application must also be filed at the same library no later than ten (10) days after submitting the information to the IDEM, OAQ. Failure to comply with public notice and library filing requirements may result in the denial of your permit application. Refer to the general instructions and the Online Permit Guide for more information on the public notice statutes applicable to your source. 50. Name of Library: Provide the name of the library that will be retaining a copy of your permit application and related materials for public review. You must choose the library that is nearest to the source and within the same county where the source is located. If more than one library will be retaining a copy of your permit application, please give us information for each library. 51. Name of Librarian: (Optional) Provide a contact person for the local library. 52. Mailing Address: Provide the mailing address for the local library. 53. Internet Address: (Optional) Provide the Internet address (website) for the local library. 54. Electronic Mail Address: (Optional) Provide the electronic mail (email) address for the local library (or for the librarian). 55. Telephone Number: Provide the telephone number for the local library (or for the librarian). 56. Facsimile Number: (Optional) Provide the facsimile number for the local library. Part I: Company Name History (If Applicable) Part I lists the legal names used by the source since issuance of the last operating permit. Complete this table only if the applicant has previously operated under a legal name that is different from the name listed above in Section A. 57. Legal Name of Company: List each name that was used by the company since issuance of the last operating permit for this source. 58. Dates of Use: For each name listed, provide the dates the name was used by the company. 59. Company Name Change Request: Is the source officially requesting to change the legal name that will be printed on all official documents issued by IDEM, OAQ? Check “No” if the applicant does not wish to make an official change to the legal name of the company to be used on all official documents issued by IDEM, OAQ. Answering “Yes” to this question will trigger processing of an official request to change the company’s name, and the applicant must provide the new name of the company as it should be written on all official documents. American LegalNet, Inc. www.FormsWorkflow.com Part J: Portable Source Location History (If Applicable) Part J lists the past locations of the portable source since issuance of the last operating permit. Complete this table only if this is a portable source and the location has changed since the previous permit was issued. The current location of the portable source should be listed in Section A. 60. Plant ID: Provide the plant ID for each location of the portable source. 61. Location of Portable Source: List each location where the portable source operated since issuance of the last operating permit for this source. 62. Dates of Use: For each name listed, provide the dates the source operated at that location. Part K: Request to Change Location of Portable Source (If Applicable) Complete Part K to request a change of location for a portable source. 63. Current Location: Provide the address where the portable source is currently located. 64. New Location: Provide the next address where the portable source is will be located. Part L: Source Process Description Part L identifies the full process description of the primary and any secondary or support operations at this source including identification of products, SIC Codes, and NAICS Codes. 65. Process Description: Identify the main processes for this source. The primary process should be listed first, followed by any secondary or support operations. 66. Products: Identify the products associated with each of the process(es) identified. 67. SIC Code: Identify the Source Industrial Classification (SIC) Codes that correspond to the process(es) identified. 68. NAICS Code: Identify the North American Industrial Classification System (NAICS) Codes that correspond to the processes identified. If you already know the SIC code for the industrial process, you may cross-reference the code with a NAICS code by using the NAICS/SIC cross-reference table. Many SIC codes do not directly cross-reference with NAICS codes; if this is the case, then choose the NAICS code(s) that best describes your manufacturing operation(s). NOTE: The NAICS Codes are slated to replace the SIC Codes for permitting and reporting purposes after December 31, 2002. Part M: Existing Approvals (If Applicable) Part M identifies all air operating and construction permit numbers and their corresponding emissions unit identification numbers. Please list the permit in order of the most recent/current permit to the oldest/original permit. 69. Permit ID: Provide all permit identification numbers associated with this source. NOTE: A copy of each permit identified above must be attached to this permit application. 70. Emissions Unit IDs: Provide the emissions unit identification number for every emissions unit that is associated with the listed permit. These identification numbers should correspond to the identification given to the emissions unit when completing subsequent air permit application forms. If any of the emissions units have been previously permitted under a different identification number, please attach documentation of the changes that resulted in the renumbering of the emissions unit(s). It may be necessary to include additional pages if there are several existing approvals for this source. American LegalNet, Inc. www.FormsWorkflow.com 71. Expiration Date: Provide the expiration date of the listed permit. The expiration date will be noted on the cover page of your permit. Most approvals expire five (5) years after the issuance date. All sources are required to submit an application to renew their permit prior to the expiration date. If you do not know whether your permit has an expiration date, contact the air permit reviewer of the day at (317) 2330178 or 1-800-451-6027 extension 3-0178 (toll free call within Indiana). Part N: Unpermitted Emissions Units (If Applicable) Part N identifies all unpermitted emissions units. 72. Emissions Unit ID: Provide the identification number for every emissions unit that is currently unpermitted. This question also applies to insignificant and/or trivial emissions units that do not require pre-construction approval. These identification numbers should correspond to the identification given to the emissions unit when completing subsequent air permit application forms. It may be necessary to include additional pages if there are several unpermitted emissions units for this source. Comment [O1]: For this section, is there any information that we need in order to make a determination of nested / co-located / other sources with regard to NSR? 73. Type of Emissions Unit: Provide a short description that defines the type of emissions unit. For example, most sources have at least one emissions unit that is used to provide heat to a building or to provide steam for process. In the first case, you would refer to the emissions unit as a “Process Heater,” but in the second case, you would refer to the emissions unit as a “Boiler.” 74. Actual Dates: Provide the actual date when construction began for the emissions unit, when construction was completed, and when you began operating the emissions unit. NOTE: If the emissions unit has not yet been constructed, you should be using Part O, New or Modified Emissions Units, to enter information on that emissions unit. If you have begun construction on the emissions unit, but have not yet completed this construction process, you should enter the estimated dates for both the construction completion date and the date you intend to begin operation of the emission unit. If you constructed the emissions unit, but have not yet begun operating the emissions unit, you should enter an estimation of the date you intend to begin operating the emission unit. Part O: New or Modified Emissions Units (If Applicable) Part O identifies all proposed new construction including the addition of new process emissions units and modifications to existing emissions units. 75. Emissions Unit ID: Provide the identification number for every proposed new emissions unit that is to be constructed and for every emissions unit for which you are proposing modifications. These identification numbers should correspond to the identification given to the emissions unit when completing subsequent air permit application forms. It may be necessary to include additional pages if there are several new emissions units and/or modifications proposed for this source. 76. NEW: Place a check mark in this cell if the emissions unit is new construction. 77. MOD: Place a check mark in this cell if the emissions unit is being modified. 78. Type of Emissions Unit: Provide a short description that defines the type of emissions unit. For example, many sources have surface coating operations. You would refer to the corresponding emissions unit as a “Paint Booth.” 79. Estimated Dates: Provide an estimation of the dates when construction for the emissions unit will begin, when construction will be completed, and when you intend to begin operating the emissions unit. American LegalNet, Inc. www.FormsWorkflow.com NOTE: If the emissions unit is under construction, has already been completely constructed, and/or is currently operating, you should be using the Part N, Unpermitted Emissions Units, to enter information on that emissions unit. ***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 OAQ GENERAL SOURCE DATA APPLICATION GSD-01: Basic Source Level Information IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue, 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/permits/air/index.html State Form 50640 (R4 / 9-06) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT • The purpose of GSD-01 is to provide essential information about the entire source of air pollutant emissions. GSD-01 is a required form. • Detailed instructions for this form are available online at http://www.in.gov/idem/permits/air/apps/instructions/. • NOTES: 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 public inspection. PART A: Source / Company Location Information 1. Source / Company Name: – 2. Plant ID: 3. Location Address: City: State: 4. County Name: ZIP Code: – 5. Township Name: 6. Geographic Coordinates: Latitude: Longitude: 7. Universal Transferal Mercadum Coordinates (if known): Zone: Horizontal: Vertical: 8. Adjacent States: Is the source located within 50 miles of an adjacent state? No Yes – Indicate Adjacent State(s): Illinois (IL) Michigan (MI) Ohio (OH) Kentucky (KY) 9. Attainment Area Designation: Is the source located within a non-attainment area for any of the criteria air pollutants? No Yes – Indicate Nonattainment Pollutant(s): CO Pb NOx 10. Portable / Stationary: Is this a portable or stationary source? O3 PM PM10 Portable PM2.5 SO2 Stationary PART B: Source Summary 11. Company Internet Address (optional): 12. Company Name History: Has this source operated under any other name(s)? No Yes – Provide information regarding past company names in Part I, Company Name History. 13. Portable Source Location History: Will the location of the portable source be changing in the near future? Not Applicable No Yes – Complete Part J, Portable Source Location History, and Part K, Request to Change Location of Portable Source. 14. Existing Approvals: Have any exemptions, registrations, or permits been issued to this source? No Yes – List these permits and their corresponding emissions units in Part M, Existing Approvals. 15. Unpermitted Emissions Units: Does this source have any unpermitted emissions units? No Yes – List all unpermitted emissions units in Part N, Unpermitted Emissions Units. 16. New Source Review: Is this source proposing to construct or modify any emissions units? No Yes – List all proposed new construction in Part O, New or Modified Emissions Units. 17. Risk Management Plan: Has this source submitted a Risk Management Plan? Not Required No Yes Date submitted: Continued on Next Page EPA Facility Identifier: – – Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality State Form 50640 (R4 / 9-06) Air Permit Application FORM GSD-01 Page 2 of 5 PART C: Source Contact Information IDEM will send the original, signed permit decision to the person identified in this section. This person MUST be an employee of the permitted source. 18. Name of Source Contact Person: 19. Title (optional): 20. Mailing Address: City: State: ZIP Code: – 21. Electronic Mail Address (optional): 22. Telephone Number: ( ) – 23. Facsimile Number (optional): ( ) – PART D: Authorized Individual/Responsible Official Information IDEM will send a copy of the permit decision to the person indicated in this section, if the Authorized Individual or Responsible Official is different from the Source Contact specified in Part C. 24. Name of Authorized Individual or Responsible Official: 25. Title: 26. Mailing Address: City: State: 27. Telephone Number: ( ) – ZIP Code: 28. Facsimile Number (optional): ( – ) – 29. Request to Change the Authorized Individual or Responsible Official: Is the source officially requesting to change the person designated as the Authorized Individual or Responsible Official in the official documents issued by IDEM, OAQ? The permit may list the title of the Authorized Individual or Responsible Official in lieu of a specific name. No Yes – Change Responsible Official to: PART E: Owner Information 30. Company Name of Owner: 31. Name of Owner Contact Person: 32. Mailing Address: City: 33. Telephone Number: ( State: ) – ZIP Code: 34. Facsimile Number (optional): ( – ) – 35. Operator: Does the “Owner” company also operate the source to which this application applies? No – Proceed to Part F below. Yes – Enter “SAME AS OWNER” on line 35 and proceed to Part G below. PART F: Operator Information 36. Company Name of Operator: 37. Name of Operator Contact Person: 38. Mailing Address: City: 39. Telephone Number: ( State: ) – ZIP Code: 40. Facsimile Number (optional): ( Continued on Next Page – ) – American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality State Form 50640 (R4 / 9-06) Air Permit Application FORM GSD-01 Page 3 of 5 PART G: Agent Information 41. Company Name of Agent: 42. Type of Agent: Environmental Consultant Attorney Other (specify): 43. Name of Agent Contact Person: 44. Mailing Address: City: State: ZIP Code: – 45. Electronic Mail Address (optional): 46. Telephone Number: ( ) – 47. Facsimile Number (optional): ( 48. Request for Follow-up: Does the “Agent” wish to receive a copy of the preliminary findings during the public notice period (if applicable) and a copy of the final determination? ) – No Yes PART H: Local Library Information 49. Date application packet was filed with the local library: 50. Name of Library: 51. Name of Librarian (optional): 52. Mailing Address: City: State: ZIP Code: – 53. Internet Address (optional): 54. Electronic Mail Address (optional): 55. Telephone Number: ( ) – 56. Facsimile Number (optional): ( ) – PART I: Company Name History (if applicable) Complete this section only if the source has previously operated under a legal name that is different from the name listed above in Section A. 57. Legal Name of Company 58. Dates of Use to to to to to to to to to to 59. Company Name Change Request: Is the source officially requesting to change the legal name that will be printed on all official documents issued by IDEM, OAQ? No Yes – Change Company Name to: Continued on Next Page American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality State Form 50640 (R4 / 9-06) Air Permit Application FORM GSD-01 Page 4 of 5 PART J: Portable Source Location History (if applicable) Complete this section only if the source is portable and the location has changed since the previous permit was issued. The current location of the source should be listed in Section A. 60. Plant ID 61. Location of the Portable Source 62. Dates at this Location – to – to – to – to – to – to – to – to – to – to – to – to – to – to – to – to – to – to – to – to PART K: Request to Change Location of Portable Source (if applicable) Complete this section to request a change of location for a portable source. 63. Current Location: Address: City: State: ZIP Code: – State: ZIP Code: – County Name: 64. New Location: Address: City: County Name: Continued on Next Page American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality State Form 50640 (R4 / 9-06) Air Permit Application FORM GSD-01 Page 5 of 5 PART L: Source Process Description Complete this section to summarize the main processes at the source. 65. Process Description 66. Products 67. SIC Code 68. NAICS Code PART M: Existing Approvals (if applicable) Complete this section to summarize the approvals issued to the source since issuance of the main operating permit. 69. Permit ID 70. Emissions Unit IDs 71. Expiration Date PART N: Unpermitted Emissions Units (if applicable) Complete this section only if the source has emission units that are not listed in any permit issued by IDEM, OAQ. 74. 72. Emissions Unit ID 73. Type of Emissions Unit Actual Dates Began Completed Construction Construction Began Operation 77. MOD 75. Emissions Unit ID 76. NEW PART O: New or Modified Emissions Units (if applicable) Complete this section only if the source is proposing to add new emission units or modify existing emission units. 79. 78. Type of Emissions Unit Estimated Dates Begin Construction Complete Construction Begin Operation American LegalNet, Inc. www.FormsWorkflow.com