Attachment 1 Submittal Forms.pdf

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Form Approved OMB No. 2060-0256

ENVIRONMENTAL PROTECTION AGENCY

REFRIGERANT RECOVERY OR RECYCLING DEVICE

ACQUISITION CERTIFICATION FORM

EPA regulations require establishments that service or dispose of refrigeration or air-conditioning equipment to certify that they have acquired recovery or recycling devices that meet EPA standards for such devices. To certify that you have acquired equipment, please complete this form according to the instructions and mail it to the appropriate EPA Regional Office. BOTH THE INSTRUCTIONS AND MAILING ADDRESSES CAN BE FOUND ON THE

REVERSE SIDE OF THIS FORM.

PART 1: ESTABLISHMENT INFORMATION

Name of Establishment Street

(Area Code) Telephone Number City State Zip Code

Number of Service Vehicles Based at Establishment County

PART 2: REGULATORY CLASSIFICATION

Identify the type of work performed by the establishment. Check all boxes that apply.

9 Type A - Service small appliances 9 Type B - Service refrigeration or air-conditioning equipment other that small appliances 9 Type C- Dispose of small appliances 9 Type D - Dispose of refrigeration or air-conditioning equipment other than small appliances

PART 3: DEVICE IDENTIFICATION

Name of Device(s) Manufacturer Model Number Year Serial Number (if any) Check Box if Self-Contained

1. G

2. G

3. G

4. G

5. G

PART 4: CERTIFICATION SIGNATURE

I certify that the establishment in Part 1 has acquired the refrigerant recovery or recycling device(s) listed in Part 2, that the establishment is complying with Section 608 regulations, and that the information gives is true and correct.

Signature of Owner/Responsible Officer Date Name (Please Print) Title

INSTRUCTIONS

Part 1: Please provide the name, address, and telephone number of the establishment where the refrigerant recovery or recycling device(s) is (are) located. Please complete one form for each location.

State the number of vehicles based at this location that are used to transport technicians and equipment to and from service sites.

Part 2: Check the appropriate boxes for the type of work performed by technicians who are employees of the establishment. The term “small appliance” refers to any of the following products tat are fully manufactured, charged, and hermetically sealed in a factory with five pounds or less of refrigerant:

refrigerators, and freezers designed for home use, room air conditioners (including window air conditioners and packaged terminal air conditioners), packaged terminal heat pumps, dehumidifiers, under-the-counter ice makers, vending machines, and drinking water coolers.

Part 3: For each recovery or recycling device acquired, please list the name of the manufacturer of the device, and (if applicable) its model number and serial number.

If more that seven devices have been acquired, please fill out an additional form and attach it to this one. Recovery devices that are self-contained should be listed first and should be identified by checking the box in the last column on the right. Self-contained recovery equipment means refrigerant recovery or recycling equipment that is capable of removing te refrigerant from an appliance without the assistance of components contained in the appliance. On the other hand, system-dependent recovery equipment means refrigerant recovery equipment that requires the assistance of components contained in an appliance to remove the refrigerant from the appliance.

If the establishment has been listed as Type B and/or Type D in Part 2, then the first device listed in Part # must be a self-contained device and identifies as such by checking the box in the last column on the right.

If any of the devices are homemade, they should be identified by writing “homemade” in the column provided for listing the name of the device manufacturer. Type A or Type B establishments can use homemade devices manufactured before November 15, 1993. Type C or Type D establishments can use homemade manufactured anytime. If, however, a Type C or Type D establishment is using homemade equipment manufactured after November 15, 1993, then it must not use these devices for service jobs.

EPA REGIONAL OFFICES

Send your form to the EPA office listed under the state or territory in which the establishment is located.

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

CAA 608 Enforcement Contact: EPA Region I; Mail Code SEA; JFK Federal Building; One Congress Street, Suite 1100; Boston, MA 02114-2023

Arkansas, Louisiana, New Mexico, Oklahoma, Texas

CAA 608 Enforcement Contact: EPA Region VI; Mail Code 6EN-AA; 1445 Ross Ave., Suite 1200; Dallas, TX 75202

New York, New Jersey, Puerto Rico, Virgin Islands

CAA 608 Enforcement Contact: EPA Region II; Mail Code 2DECA-AC; 290 Broadway; New York, NY 10007-1866

Iowa, Kansas, Missouri, Nebraska

CAA 608 Enforcement Contact: EPA Region VII; Mail Code APCOARTD; 901 North Fifth Street; Kansas City, KS 66101

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

CAA 608 Enforcement Contact: EPA Region III-Wheeling Office; Mail Code 3AP12; 303 Methodist Building; 11th and Chapline Streets; Wheeling, WV 26003

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

CAA 608 Enforcement Contact: EPA Region VIII; Mail Code 8ENF-T; 999 18th

Street, Suite 500; Denver, CO 80202

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

CAA 608 Enforcement Contact: EPA Region IV; Mail Code APT-AE; 61 Forsyth Street, SW; Atlanta, GA 30303-8960

American Samoa, Arizona, California, Guam, Hawaii, Nevada

CAA 608 Enforcement Contact: EPA Region IX; Mail Code AIR-5; 75 Hawthorne Street; San Francisco, CA 94105

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

CAA 608 Enforcement Contact: EPA Region V; Mail Code AE-17J; 77 West Jackson Blvd.; Chicago, IL 60604

Alaska, Idaho, Oregon, Washington

CAA 608 Enforcement Contact: EPA Region X; Mail Code OAQ-107; 1200 Sixth Ave.; Seattle, WA 98101

BOB.MILLENBACH

Typewritten Text

Proposed Project Emissions Inventory Questionnaire for New Sources

TCEQ Title V Operating Permit Decision Support System

The Decision Support System provides several documents linked together to aid in the Title V application and review process. These documents include Rule Text, Relationship Entry Screens, Flowcharts and Historic Rule Opinions (when applicable). Most of these documents and their subparts are available in Portable Document Format(PDF). To view the documents in this format, a free copy of Adobe Acrobat Reader will have to be installed on your computer. For best results, install the most current version of Adobe Reader.

For information on installing or configuring the Adobe Acrobat Reader click here. Even if you have the Adobe Acrobat Reader installed, you may need to configure it to work as required (The hyperlinking capability will not work unless the reader opens up within the browser window).

Guidance for using the Decision Support System Decision Support System for:

40 CFR Part 59 - National Volatile Organic Compound Emission Standards for Consumer and Commercial Products 40 CFR Part 60 - Standard of Performance for New Stationary Sources(NSPS) 40 CFR Part 61 - National Emission Standards for Hazardous Air Pollutants (NESHAPS) 40 CFR Part 63 - National Emission Standards for Hazardous Air Pollutants for Source Categories(a.k.a. Maximum Achievable Control Technology (MACT)) 40 CFR Part 82 - Protection of Stratospheric Ozone 30 TAC Chapters 39, 101-122 - Control of Air Pollution

Applicability Determination Index (ADI)

The EPA also has a database available online that contains memoranda issued by the the agency on applicability and compliance issues associated with NSPS, NESHAP and MACT Standards

Requestor: ____________________________ Date: _____________ Phone: _____________ Project # _____________________________ Facility Name / Building Number: ____________________________ Descriptive Name of Facility: ______________________________________________ Location of Facility: UTM Zone: 14 Horizontal Coordinate _____________________E Vertical Coordinate ____________________N

Indicate proposed emission source type and complete all applicable fields for each process.

Complete questionnaire sheet for each process type in this facility.

http://www.tnrcc.state.tx.us/link.html http://www.tnrcc.state.tx.us/link.html http://www.adobe.com/ http://www.adobe.com/ http://www.tnrcc.state.tx.us/permitting/airperm/opd/pdfhelp.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/pdfhelp.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/dssgui.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/dssgui.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/59/59hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/59/59hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/60/60hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/60/60hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/61/61hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/61/61hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/63/63hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/63/63hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/82/82hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/82/82hmpg.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/state/statehp.htm http://www.tnrcc.state.tx.us/permitting/airperm/opd/state/statehp.htm http://www.epa.gov/compliance/planning/data/air/adi.html http://www.epa.gov/compliance/planning/data/air/adi.html

INTERNAL COMBUSTION UNITS (I.E. GENERATORS, ENGINE TEST CELLS)

(Covered by 30 TAC 106.511 and 30 TAC 106.261)

Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons Make_________________ Model_____________ Serial #________________ Power Rating: ____kw; Horsepower: ___ HP Fuel Type: ________________ MUR/JP8/Diesel; Integrated Fuel Tank Capacity: __________gallons

Separate Fuel Tank(s): YES / NO (circle one) Complete Separate Questionnaire for Each Tank Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____ hours/day _____days/week _____ weeks/year____ Normal Operating Rate: _______________gallons or CuFt/ year

FUEL STORAGE TANKS (Covered by 30 TAC 115.473 , 30 TAC 106.478 and 30 TAC Chap 115)

Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________ Make__________________Model_________________Serial #______________ Fuel Type: _____________ Tank Volume: __________gals;Tank Dimensions (ft): Diameter _______Length_______ Height________

Tank Type: Aboveground / Underground (circle one); Vapor Control Equipped: YES / NO (circle one) Roof Type: Horizontal Fixed Roof / Vertical Fixed Roof / Internal Floating Roof / Pressure Tank External Floating Roof

Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____hours/day _____days/week _____weeks/year_____ Normal Operating Rate: _______________gallons/year Maximum Operating Rate: _______________gallons/hour

EXTERNAL COMBUSTION UNITS (Boilers, Hot Water Heaters, Process Heaters) (Covered by 30 TAC 106.102 and 30 TAC 106.183) Fuel Type: Natural Gas / Diesel Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec Make__________________Model_________________Serial #___________________ Input Rating: __________ MMBTUH Height of Stack: __________ ft ; Diameter of Stack: __________ ft; Stack Exhaust Velocity: ______________ft / sec

Seasonal Operating Percentage for These Emission Points:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____ hours/day _____days/week _____ weeks/year____ Normal Operating Rate:

_______________gallons/year

FUEL DISPENSING UNITS (Covered by 30 TAC 106.412) Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________

Fuel Type: MUR / Diesel / JP-8 / Other ______________ (circle one) Dispensing Type: Retail / Bulk (circle one) Vapor Control Equipped : YES / NO (circle one) Dispenser Pump rate: __________ gallons/minute Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____ hours/day _____days/week _____ weeks/year____ Normal Operating Rate: _______________gallons/year http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=511 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=511 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=263 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=263 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=473 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=473 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=478 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=478 http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=5&ti=30&pt=1&ch=115&sch=C http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=5&ti=30&pt=1&ch=115&sch=C http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=102 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=102 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=183 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=183 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=412 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=412

SURFACE COATING OPERATIONS (Covered by 30 TAC 106.433 , 30 TAC 106.436 or 30 TAC 116.110)

Attach approved MSDS of each coating and solvent used in process Particulate Matter Control Efficiency of Booth: __________% Booth Air Flow Rate:___________scfm Transfer Efficiency of Paint Gun: __________% Number of Paint Guns: __________ Associated Heater: YES / NO (circle one) Complete Separate Questionnaire for Each Heater Associated Gun Cleaner: YES / NO (circle one) Complete Separate Questionnaire for Each Cleaner Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____hours/day _____days/week _____weeks/year____ Normal Operating Rate: _______________gallons/year (each coating and solvent)

REFRIGERATION EQUIPMENT (AIR CONDITIONING SYSTEM, FREEZER) (Covered by 30 TAC 106.103)

Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____ Make__________________ Model____________Serial#___________________ No. of compressors: ______ Refrigerant Type: __________ Amount of Charge:______lbs; Initial Charge Date:_____/_____/_____

Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100% Normal Operating Schedule: Start Time_____hours/day _____days/week _____weeks/year_____

WELDING OPERATIONS (Covered by 30 TAC 106.227)

Attach approved MSDS of each welding rod type used in process Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________

Particulate Matter Control Efficiency of hood (if available): __________% Exhaust Fan Ventilation Rate :___________scfm Acetylene on hand: __________lbs of gas Oxygen on hand: __________ lbs of gas Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100%

Normal Operating Rate: _______________# of rods/year

BRAKE REPAIR OPERATIONS (Covered by 30 TAC 106.261 and 30 TAC 106.262)

Attach approved MSDS of each brake pad type used in process Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________ Make__________________Model_________________Serial #___________________

Particulate Matter Control Efficiency of hood (if available): 1st Stage ________%; 2nd Stage_____% Exhaust Fan Ventilation Rate :___________scfm Seasonal Operating Percentage for This Emission Point:

Spring _____% Summer _____% Fall _____% Winter _____% Note: Total Must Equal 100%

Normal Operating Rate: _______________# of Brakes Repaired/year http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=433 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=433 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=436 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=436 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=116&rl=110 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=116&rl=110 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=103 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=103 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=227 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=227 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=261 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=261 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=262 http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=30&pt=1&ch=106&rl=262

ENV Use Only FIN, EPN and CIN determination comes from Emissions Inventory Guidelines

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN # _________________ EPN #_________________ CIN #__________________

FIN- Facility Identification Number; EPN- Emission Point Number; CIN- Control Identification Number

ENV Use Only Received on __________ for submittal in _________ Permit

AUTHORIZATION TO PROCEED WITH CHANGE

Authorized by: ____________________ Title: ______________________ Signature: ________________________ Date: ______________________

AUTHORIZATION FOR STARTUP

Authorized by: ____________________ Title: ______________________

Proposed Project Emissions Inventory Questionnaire for New Sources http://www.tnrcc.state.tx.us/air/aqp/psei.html http://www.tnrcc.state.tx.us/air/aqp/psei.html

BOB.MILLENBACH

Typewritten Text

PRIME COMPANY NAME: _______________________________ CONTRACT NO: _______________________

PROJECT TITLE/LOCATION: ___________________________________________________________________

Material Name Manufacturer MSDS State Number

Average Max Daily Daily

*Contractor(s) certifies that the hazardous material(s) removed from installation will be used/reused for its intended purpose.

Submitted By: Phone: Fax:_______ Date:

Printed Name

Contracting Officer Phone: Fax:_______ or Representative Page____of____

CONTRACTOR HAZARDOUS MATERIAL INVENTORY & CONSUMPTION LOG

(EPCRA/E.O. 13423)

(container size-quantity of) Storage Quantity Quantity (lbs/gals) used in CY [ ](i.e. Liquid, Solid, Gas)

Company Using Material Listed Above Company Representative's Signature

.03 REFERENCES

PART 3 EXECUTION

PART 3 EXECUTION

.03 REFERENCES

PART 3 EXECUTION

.03 MATERIAL TESTING