Free 50639.pdf - Indiana

AIR PERMIT APPLICATION COVER SHEET
State Form 50639 (R3 / 11-07)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

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IDEM - Office of Air Quality - Permits Branch 100 N. Senate Avenue, MC 61-53, 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 this cover sheet is to obtain the core information needed to process the air permit application. This cover sheet is required for all air permit applications submitted to IDEM, OAQ. Place this cover sheet on top of all subsequent forms and attachments that encompass your air permit application packet. Submit the completed air permit application packet, including all forms and attachments, to IDEM Air Permits Administration using the address in the upper right hand corner of this page. Also send a copy to the local agency (if applicable). IDEM will send a bill to collect the filing fee and any other applicable fees. Detailed instructions for this form are available online at
www.in.gov/idem/permits/air/apps/instructions/coverinstructions.html.

FOR OFFICE USE ONLY
PERMIT NUMBER: ____ ______ ­ __________ ­ ____________

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DATE APPLICATION WAS RECEIVED:

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1. Tax ID Number:

PART A: Purpose of Application Part A identifies the purpose of this air permit application. For the purposes of this form, the term "source" refers to the plant site as a whole and NOT to individual emissions units.
2. Source / Company Name: 4. Billing Address: City: 5. Permit Level: Exemption Registration State: SSOA MSOP ZIP Code: FESOP TVOP ­ PBR 3. Plant ID:

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6. Application Summary: Check all that apply. Multiple permit numbers may be assigned as needed based on the choices selected below. Initial Permit Review Request Interim Approval Site Closure Renewal of Operating Permit Revocation of Operating Permit Relocation of Portable Source Emission Reduction Credit Registry From:
Company Name Change Correction to Non-Technical Information

Asphalt General Permit Alternate Emission Factor Request Acid Deposition (Phase II)

Transition (between permit levels) Administrative Amendment:

To:
Change of Responsible Official Notice Only Change

Other (specify): Modification:
New Emission Unit or Control Device New Applicable Permit Requirement Prevention of Significant Deterioration Minor Source Modification Minor Permit Modification Other (specify): Modified Emission Unit or Control Device Change to Applicability of a Permit Requirement Emission Offset MACT Preconstruction Review

Significant Source Modification Significant Permit Modification

7. Is this an application for an initial construction and/or operating permit for a "Greenfield" Source? 8. Is this an application for construction of a new emissions unit at an Existing Source?

Yes Yes

No No

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Indiana Department Of Environmental Management Office Of Air Quality State Form 50639 (R3 / 11-07)

Air Permit Application Cover Sheet Page 2 of 2

PART B: Pre-Application Meeting Part B specifies whether a meeting was held or is being requested to discuss the permit application.
9. Was a meeting held between the company and IDEM prior to submitting this application to discuss the details of the project? No Yes: Date:

10. Would you like to schedule a meeting with IDEM management and your permit writer to discuss the details of this project? No Yes: Proposed Date for Meeting:

PART C: Confidential Business Information Part C identifies permit applications that require special care to ensure that confidential business information is kept separate from the public file.
Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in the Indiana Administrative Code (IAC). 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.

11. Is any of the information contained within this application being claimed as Confidential Business Information? Yes No

PART D: Certification Of Truth, Accuracy, and Completeness Part D is the official certification that the information contained within the air permit application packet is truthful, accurate, and complete. Any air permit application packet that we receive without a signed certification will be deemed incomplete and may result in denial of the permit.
For a Part 70 Operating Permit (TVOP) or a Source Specific Operating Agreement (SSOA), a "responsible official" as defined in 326 IAC 2-7-1(34) must certify the air permit application. For all other applicants, this person is an "authorized Individual" as defined in 326 IAC 2-1.1-1(1).

I certify under penalty of law that, based on information and belief formed after reasonable inquiry, the statements and information contained in this application are true, accurate, and complete.

Name (typed)

Title

Signature

Date (month, day, year)