OAQ PERMIT RENEWAL APPLICATION Air Permit Renewal Checklist State Form 51755 (R / 12-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue, MC 61-53, IGCN 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/permits/air/index.html • The purpose of the Air Permit Application Renewal Checklist is to provide a worksheet for quickly assessing whether the air permit renewal application includes all necessary information. • NOTES: Detailed instructions for this checklist are available online at www.in.gov/idem/permits/air/apps/instructions/renewalinstructions.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 public inspection. Air Permit Renewal Checklist Complete the checklist, placing a check in the box corresponding to the completion status of each item listed. 1. 2. 3. INFORMATION PROVIDED NOT APPLICABLE Original Air Operating Permit Number: Air Permit Application Cover Sheet – includes application tracking information and the signed certification for the renewal application General Source Data (GSD-01) Form – includes basic source information, contact information, process/emissions unit update information, and local library information 4. Compliance Schedule and Certification (CD-04) Form (Title V Sources Only). 5. Compliance Assurance Monitoring (CAM) Form - FED-03 (Title V Sources Only). List of exempt, trivial and/or insignificant activities added since issuance of the original permit (if applicable) List of emission units removed since issuance of the original permit (if applicable) List of all Notice Only Changes, Administrative Amendments, Revisions, and/or Modifications to the original Air Operating Permit. 6. 7. 8. ⇒ List Permit Numbers Below: Documentation illustrating any changes to the original operating permit needed/requested beyond what has already been approved through a permit action. The responsible official (or authorized individual) has certified the air permit 10. application by signing the application cover sheet. Notes: This space is being provided for inclusion of any additional notes that may assist IDEM, OAQ in preparing the 11. renewal permit. You may also attach a letter to the air permit renewal application if additional clarification is needed. 9. Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com