Appendix C - NHDES Air Permit Application.doc

NHDES-A-02-009

ARD-1 fORM general facility information

Air Resources Division/Permitting and Environmental Health Bureau

RSA/Rule: RSA 125-C:12 and Env-A 1700 This ARD-1 General Facility Information form shall be submitted with every application for an air permit.

1. TYPE OF FACILITY1

Title V Non-Title V

Unknown

2. TYPE OF PERMIT2

Temporary Permit (Construction)

State Permit to Operate

Title V Operating Permit

General State Permit

Limitation on Potential to Emit (Env-A 625)

3. TYPE OF APPLICATION3

New

Renewal

Modification

Administrative Amendment

4. FACILITY INFORMATION

FACILITY NAME4:

AFS NUMBER5:

PHYSICAL ADDRESS:

TOWN/CITY:

STATE:

ZIP:

GOVERNMENT FACILITY CODE6:

5. BUSINESS INFORMATION AS REGISTERED WITH SECRETARY OF STATE7 (If applicable)

REGISTERED NAME:

REGISTERED ADDRESS:

TOWN/CITY:

STATE:

ZIP:

6. PARENT CORPORATION INFORMATION (If applicable)

PARENT CORPORATION NAME:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

7. MAJOR ACTIVITY OR PRODUCT DESCRIPTION

List all activities performed at this facility and provide SIC and/or NAICS Code(s)8.

SIC Code

Activity Description

NAICS Code

Activity Description

At a minimum, please provide contact information below for Responsible Official, Technical, Invoicing and Legal contacts. Make as many copies of this page as necessary in order to include all contacts that you wish to associate with the application. Multiple people can be assigned one role; multiple roles can be assigned to one person.

8. RESPONSIBLE OFFICIAL INFORMATION

RESPONSIBLE OFFICIAL NAME9:

TITLE:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

EMAIL ADDRESS:

FAX NUMBER:

ROLES:

Responsible Official Technical Invoicing

Legal

Prepared Application Corporate Owner/Operator Consultant

9. ADDITIONAL CONTACT INFORMATION

CONTACT NAME:

TITLE:

COMPANY NAME:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

EMAIL ADDRESS:

TELEPHONE NUMBER:

EXTENSION:

FAX NUMBER:

ROLES:

Responsible Official Technical

Owner/Operator Consultant

10. ADDITIONAL CONTACT INFORMATION

CONTACT NAME:

TITLE:

COMPANY NAME:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

EMAIL ADDRESS:

TELEPHONE NUMBER:

EXTENSION:

FAX NUMBER:

ROLES:

Responsible Official Technical

Owner/Operator Consultant

11. ADDITIONAL CONTACT INFORMATION

CONTACT NAME:

TITLE:

COMPANY NAME:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

EMAIL ADDRESS:

TELEPHONE NUMBER:

EXTENSION:

FAX NUMBER:

ROLES:

Responsible Official Technical

Owner/Operator Consultant

12. ADDITIONAL CONTACT INFORMATION

CONTACT NAME:

TITLE:

COMPANY NAME:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

EMAIL ADDRESS:

TELEPHONE NUMBER:

EXTENSION:

FAX NUMBER:

ROLES:

Responsible Official Technical

Owner/Operator Consultant

13. ADDITIONAL CONTACT INFORMATION

CONTACT NAME:

TITLE:

COMPANY NAME:

MAILING ADDRESS:

TOWN/CITY:

STATE:

ZIP:

EMAIL ADDRESS:

TELEPHONE NUMBER:

EXTENSION:

FAX NUMBER:

ROLES:

Responsible Official Technical

Owner/Operator Consultant

This section of the form must be completed and signed by the Responsible Official only.

14. CERTIFICATIONS

I certify that the applicant, or the owner or operator the applicant represents, has right, title, or interest in all of the property that is proposed for development or use because the owner or operator owns, leases, or has binding options to purchase all of the property proposed for development or use.

I am authorized to make this submission on behalf of the affected source or affected units for which this submission is made. I certify under penalty of law that I have personally examined, and am familiar with, the information submitted in this document and all of its attachments. Based on my inquiry of those individuals with primary responsibility for obtaining the information, I certify that the statements and information are to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant penalties for submitting false statements and information or omitting required statements and information, including the possibility of fine or imprisonment.

15. RESPONSIBLE OFFICIAL INFORMATION AND SIGNATURE

RESPONSIBLE OFFICIAL NAME:

TITLE:

ARD-1 GENERAL FACILITY INFORMATION INSTRUCTIONS

List of Title V facilities in NH: http://des.nh.gov/organization/divisions/air/pehb/tvs/table.htm

Most facilities are Non-Title V. Check Unknown if you are unsure.

Temporary Permit = New Construction at Existing or New Facility

State Permit to Operate = Existing Non-Title V Facilities

Title V Operating Permit = Existing Title V Facilities

GSP = General State Permit

Limitation on Potential to Emit = Small Facilities requesting coverage under Env-A 625

New = New devices at facility, change in operation at Existing facility or New facility never permitted before

Renewal = Renewal of any permit type

Modification = Currently permitted by non-expired permit and wants to make amendment/modification to information contained in permit. This includes adding/removing devices covered by GSP.

Facility Name = Trade name or Doing Business As

AFS number is assigned by NHDES and is a 10-digit number starting with 33 (example 3300100001).

0 = Facility is not government owned 3 = Source owned by the County

1 = Source owned by the Federal Government 4 = Source owned by the Municipality

2 = Source owned by the State 5 = Source owned by the District

Name registered with NH Secretary of State: http://sos.nh.gov/corp_div.aspx Find SIC Code: https://www.osha.gov/pls/imis/sic_manual.html

Find NAICS Code: http://www.census.gov/cgi-bin/sssd/naics/naicsrch Responsible Official:

For a corporation = President, Secretary, treasurer, or vice-president in charge of a principal business function

For a partnership = General partner or proprietor

For a municipality = Principal executive officer or ranking elected official � EMBED Photoshop.Image.5 \s ��� airpermitting@des.nh.gov or phone (603) 271-1370

PO Box 95, Concord, NH 03302-0095 www.des.nh.gov

2015-03-23

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