PAL-03: PLANTWIDE APPLICABILITY LIMIT RENEWAL IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue Indianapolis, IN 46204 State Form 52453 (11-05) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 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/ NOTES: The purpose of this form is to renew an established Plantwide Applicability Limit (PAL). In order to complete your request in a timely manner, please do the following: • Attach this form to your completed application cover sheet and GSD-01. • Attach the current PAL permit. • Attach a new BACT analysis and/or NSR permit application (if needed) • Attach supplemental information behind this document. • Submit three copies of your completed request to the address in the upper right corner of this document. • Do NOT include any filing fee with the application. IDEM will bill for the PAL fee at the appropriate time. • Complete a separate request for each PAL renewal. IDEM makes all submitted information available to the public unless submitted under a claim of confidentiality. The applicant must make the claim of confidentiality at the time of submission following the requirements outlined 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: Define the PAL Identify the date the current PAL permit was issued, the pollutant that this Plantwide Applicability Limit (PAL) addresses, and the proposed PAL Level. Calculate the baseline actual emissions and the sum of the baseline actual emissions, and attach the calculations behind this form. Identify the PAL monitoring system, and include the proposed calculation procedures for converting the monitoring system data using the space provided or as an additional attachment. 1. Date current PAL permit was issued: 2. Pollutant (choose one): CO Pb NOx PM PM10 SO2 VOC 3. Proposed PAL Level (specify units): 4. Proposed calculation procedures for converting monitoring system data: Choose one: Procedures are attached Procedures are as follows: Continued on Next Page Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality State Form 52453 (11-05) Air Permit Application PAL-03: Plantwide Applicability Limit Renewal Page 2 of 3 PART B: Identify the PAL Emission Units Provide a list of all emission units at the source designated as small, significant, or major based on potential to emit (PTE). Indicate the federal and state applicable requirements, emission limitations, or work practice standards that apply to each unit. If additional space is needed, you may make a copy of this table. 5. Emission Unit 6. PTE 7. PTE Designation (small / significant / major) 8. Average Past Actual Emissions 9. (Baseline) PAL Monitoring System 10. Applicable Requirements (e.g., mass balance, CEMS, etc.) Small Units 1. tpy tpy 2. tpy tpy 3. tpy tpy 4. tpy tpy 5. tpy tpy 6. tpy tpy 7. tpy tpy 8. tpy tpy SUBTOTAL: tpy tpy 9. tpy tpy 10. tpy tpy 11. tpy tpy 12. tpy tpy 13. tpy tpy 14. tpy tpy 15. tpy tpy 16. tpy tpy SUBTOTAL: tpy tpy Significant / Major Units Continued on Next Page American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Air Quality State Form 52453 (11-05) Air Permit Application PAL-03: Plantwide Applicability Limit Renewal Page 3 of 3 PART B: Identify the PAL Emission Units (continued) Provide a list of all emission units at the source designated as small, significant, or major based on potential to emit (PTE). Indicate the federal and state applicable requirements, emission limitations, or work practice standards that apply to each unit. If additional space is needed, you may make a copy of this table. 6. Emission Unit 7. PTE 8. PTE Designation (small / significant / major) 9. Average Past Actual Emissions (Baseline) 10. PAL Monitoring System 11. Applicable Requirements (e.g., mass balance, CEMS, etc.) New / Modified Units (Increases) 17. tpy tpy 18. tpy tpy 19. tpy tpy 20. tpy tpy 21. tpy tpy 22. tpy tpy SUBTOTAL: tpy tpy Removed / Modified Units (Decreases) 23. tpy tpy 24. tpy tpy 25. tpy tpy 26. tpy tpy 27. tpy tpy 28. tpy tpy 29. tpy tpy SUBTOTAL: tpy tpy TOTAL BASELINE: tpy tpy tpy Significance Level PAL tpy tpy American LegalNet, Inc. www.FormsWorkflow.com