Free Part 2 MACT Application - Indiana

PART 2 MACT APPLICATION Application for 112(j) Case-By-Case MACT Determination
State Form 51105 (10-02) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

IDEM - Office of Air Quality - Permits Branch
100 N. Senate Avenue P.O. Box 6015 Indianapolis, IN 46206-6015 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 Http://www.IN.gov/idem/air/permits/index.html

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The purpose of the Part 2 MACT Application is to submit information about the processes and emissions units subject to Section 112(j) of the Clean Air Act (CAA) in order for IDEM, OAQ to complete a Section 112(j) case-by-case MACT Determination [40 CFR 63.53(b)]. Copies of your Part 2 MACT Application must be submitted to IDEM, OAQ (original and 2 copies), U.S. EPA Region V (1 copy), the local library (1 copy), and if applicable, the local agency (1 copy) and/or regional office (1 copy). This form is in "fillable" Adobe Acrobat PDF format. If you are unfamiliar with this format, please refer to IDEM's Q&A on PDF forms.

FOR OFFICE USE ONLY
PERMIT NUMBER: ____ ______ ­ __________ ­ ____________

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DATE APPLICATION WAS RECEIVED:

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PART A: SOURCE INFORMATION 1. Source Name: 3. SIC Code: 2. Plant ID: 4. NAICS Code: ­

5. Provide the following information regarding the location of this source. Address: City: County Name: 6. Provide the mailing address for this source. Address: City: State: PART B: LOCAL LIBRARY INFORMATION 7. Date a copy of your Part 2 MACT application was filed with your local library: 8. Name of Library: 9. Name of Librarian (optional): 10. Provide the mailing address for the library: Address: City: 11. Internet Address (optional): 12. Electronic Mail Address (optional): 13. Library Telephone No.: ( ) ­ 14. Library Facsimile No. (optional): ( ) ­ State: ZIP Code: ZIP Code: State: ZIP Code:

Township Name (optional):

PART C: CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESS 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) _________________________________________ Signature ____________________________________________ Title ____________________________________________ Date

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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 51105

Part 2 MACT Application FORM HAP-02 V10-02

DUPLICATE THIS PAGE AS NECESSARY. Support information may be provided as an attachment to this application. Be sure to identify both the source category and affected source to which any additional information applies. PART D: REQUIRED INFORMATION Complete this section for each Section 112(j) affected source category at your source. Source Category of (Example. Source Category 1 of 3)

15. Section 112(j) Source Category: Identify the Section 112(j) affected source category that applies to your source.

16. Affected Source: Identify the affected emission points or groups of affected emission points (e.g., processes or emissions units) belonging to the source category listed above for item 15. Provide the information requested in the remainder of this section for each affected source.

17. Identification of New Affected Sources: Is the affected source listed above considered a new affected source according to 40 CFR 63.51? [40 CFR 63.53(b)(1)(i)] No Yes ­ Identify the anticipated date of startup of operation:

18. Existing Limitations: Identify any existing Federal, State, or local limitations or requirements applicable to the affected source. [40 CFR 63.53(b)(1)(iii)]

19. Existing Controls: Identify any control technology or control techniques that are currently in place for the affected source. [40 CFR 63.53(b)(1)(iv)]

20. Estimation of Hazardous Air Pollutant Emissions: For each affected source listed above, identify the HAPs emitted and the total uncontrolled and controlled emissions rates for each HAP. [40 CFR 63.53(b)(1)(ii)] HAP Emitted Uncontrolled PTE (tpy) Controlled PTE (tpy)

21. MACT Floor: Are you providing any supplemental information relevant to establishing the MACT floor for this source category and affected source? [40 CFR 63.53(b)(1)(v)]

No

Yes

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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 51105

Part 2 MACT Application FORM HAP-02 V10-02

DUPLICATE THIS PAGE AS NECESSARY. Support information may be provided as an attachment to this application. Be sure to identify both the source category and affected source to which any additional information applies. PART E: OPTIONAL INFORMATION Complete this section for each affected source for which you would like to recommend Section 112(j) MACT Floor emission limitations. Source Category of (Example. Source Category 1 of 3) No Yes

22. MACT Floor: Do you have a recommendation for what the MACT floor should be for this source category and affected source? [40 CFR 63.53(b)(1)(v)]

23. MACT Emission Limitation Recommendations: If you would like to recommend emission limitations for the affected source, list the recommendation below and provide the necessary support information consistent with 40 CFR 63.52(f). Recommendations may consist of a specific design, equipment, work practice, or operational standard, or combination thereof, as an emission limitation. [40 CFR 63.53(b)(2)(i)]

24. Control Technology Description: For each recommendation listed above, provide a description of the control technologies that would be applied to meet the emission limitation. This information may include technical information on the design, operation, size, estimated control efficiency, and identification of the affected sources to which the control technologies must be applied. [40 CFR 63.53(b)(2)(ii)]

25. Monitoring Parameters: For each recommendation listed above, provide the relevant parameters to be monitored and frequency of monitoring to demonstrate continuous compliance with the MACT emission limitation over the applicable reporting period. [40 CFR 63.53(b)(2)(iii)]

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