Free 53438.pdf - Indiana

OAQ SOURCE SPECIFIC OPERATING AGREEMENT OA-01: Summary of Application and Existing Agreements
State Form 53438 (9-07)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Reset Form
NOTES: · · ·

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 form is to specify the individual operating agreements included with this application and to identify all existing operating agreements. Detailed instructions for this form are available online at www.in.gov/idem/permits/air/apps/instructions/oa01instructions.html. All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality. Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your information becoming a public record, available for any one to inspect and photocopy.

A complete SSOA Application consists of: · Application Cover Sheet, · GSD-01, General Source Information, · · · · · GSD-13, Affidavit of Applicability, GSD-14, Owners and Occupants Notified, GSD-15, Government Officials Notified, ~OR~ · GSD-12, Affidavit of Nonapplicability,

OA-01, Summary of Application and Existing Agreements Up to four (4) of the Operating Agreement forms, OA-02 through OA-14, and
Part A: Application Summary

Part A identifies the operating agreements that are included with this application. A source may apply for up to four (4) different types of source specific operating agreements provided allowable emissions or potential to emit for any regulated air pollutant, as limited under the operating agreements, do not exceed Part 70 major source levels when aggregated. 1. Requested Operating Agreement(s): Select no more than four (4). Form OA-02 326 IAC 2-9-2.5 Industrial or commercial surface coating operations not subject to 326 IAC 8-2; graphic arts operations not subject to 326 IAC 8-5-5 Surface coating or graphic arts operations Woodworking operations Abrasive cleaning operations Grain elevators Sand and gravel plants Crushed stone processing plants Ready-mix concrete batch plants Coal mines and coal preparation plants Automobile refinishing operations Degreasing operations External combustion sources Internal combustion sources TOTAL FEES (A fee bill will be mailed.): 2. Application Fee

Form OA-03 Form OA-04 Form OA-05 Form OA-06 Form OA-07 Form OA-08 Form OA-09 Form OA-10 Form OA-11 Form OA-12 Form OA-13 Form OA-14

326 IAC 2-9-3 326 IAC 2-9-4 326 IAC 2-9-5 326 IAC 2-9-6 326 IAC 2-9-7 326 IAC 2-9-8 326 IAC 2-9-9 326 IAC 2-9-10 326 IAC 2-9-11 326 IAC 2-9-12 326 IAC 2-9-13 326 IAC 2-9-14

Continued on next page

Page 1 of 2

Indiana Department Of Environmental Management Office Of Air Quality State Form 53438 (9-07)

Source Specific Operating Agreement SSOA-01: Summary of Application and Existing Agreements Page 2 of 2

Part B: Existing Operating Agreements Part B identifies all existing operating agreements. 3. Existing Operating Agreements This source does not have any existing operating agreements 326 IAC 2-9-2.5 Industrial or commercial surface coating operations not subject to 326 IAC 8-2; graphic arts operations not subject to 326 IAC 8-5-5 326 IAC 2-9-3 326 IAC 2-9-4 326 IAC 2-9-5 326 IAC 2-9-6 326 IAC 2-9-7 326 IAC 2-9-8 326 IAC 2-9-9 Surface coating or graphic arts operations Woodworking operations Abrasive cleaning operations Grain elevators Sand and gravel plants Crushed stone processing plants Ready-mix concrete batch plants 4. Permit Number 5. Date Issued

326 IAC 2-9-10 Coal mines and coal preparation plants 326 IAC 2-9-11 Automobile refinishing operations 326 IAC 2-9-12 Degreasing operations 326 IAC 2-9-13 External combustion sources 326 IAC 2-9-14 Internal combustion sources Part C: Past Emissions Part C describes the nature and amount of regulated air pollutants emitted in the previous twelve (12) months. You may complete this table or submit records of the air pollutant emissions from the previous twelve (12) months. If there are no emissions of the specified pollutant, put a zero (0) for the value and leave the units blank. 6. Time Period for Past Emissions (Example ­ January 15, 2005 through January 14, 2006):

7. Air Pollutant:
value

8. Emissions
units

Carbon Monoxide (CO) Lead (Pb) Nitrogen Oxides (NOX) Particulate Matter (PM) Particulate Matter less than 10 microns (PM10) Particulate Matter less than 2.5 microns (PM2.5) Sulfur Dioxide (SO2) Volatile Organic Compounds (VOC) Single Hazardous Air Pollutant (HAP) (specify): Total Hazardous Air Pollutants (HAP)