Free 52052.pdf - Indiana

AES-01 AIR EMISSION STATEMENT CERTIFICATION
State Form 52052 (3-05)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

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Instructions: · · ·

IDEM - Office of Air Quality Technical Support and Modeling Section - Mail Code 61-51 100 N. Senate Avenue Indianapolis, IN 46204-2251 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) http://www.emissions.IN.gov/

This is a required form for each air emission statement as well as any modifications. The certification supplied with a source's permit may be used in lieu of this form "Responsible Official" has the same meaning as defined in 326 IAC 2-7-1 (34), and is usually designated in the General Information section of the permit.

Part A: Contact Information Part A is intended to provide basic information about the company submitting an Air Emission Statement and information on the Air Emission Statement preparer in case there is a question about the report. 1. Company Name: 3. Mailing Address: City: 4. Name of Emission Statement Preparer: 5. Title of Emission Statement Preparer: (optional): 6. Telephone Number: 8. Electronic Mail Address (optional): Part B: Emissions Summary Part B is intended to aid in the review of data and to collect information about billable hazardous air pollutants Emissions Statement Pollutants (Plant Wide) Tons Emitted Carbon Monoxide (CO) Lead (PB) Nitrogen Dioxide (NO2) Particulate Matter <10 Microns (PM10) Sulfur Dioxide (SO2) Volatile Organic Compounds (VOC) Part 70 Permit Billable Hazardous Air Pollutants (Plant Wide) Tetrachloroethylene (Perc) (CAS#127184) Chlorine (CAS# 7782505) Hydrochloric Acid (CAS# 7647010) Hydrofluoric Acid (CAS# 7664393) Methyl Chloroform or 1,1,1-Trichloroethane (CAS# 71556) Methylene Chloride or Dichloromethane (CAS# 75092) Phosphine (CAS# 7803512) Mercury and Mercury Compounds (CAS#7439976 and TRI ID N458) Part C: Signature of Responsible Official I hereby certify that the information in this emission statement is accurate based on reasonable estimates using data available to the preparers and on a reasonable inquiry into records and persons responsible for the operation of the source, and is true, accurate, and complete. Tons Emitted 7. Facsimile Number (optional): State: ZIP Code: 2. Source ID:

Name of Responsible Official (typed or printed)

Title of Responsible Official

Signature of Responsible Official

Date (month, day, year)