Alaska Department of Environmental Conservation
                     Air Quality Minor Permit Application
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                     STATIONARY SOURCE IDENTIFICATION FORM


Section 1     Stationary Source Information
Name:          
SIC:          
Project Name (if different):           
Contact:               
Physical Address:          
City:                    
State:          
Zip:          

Telephone:          

E-Mail Address:          
UTM Coordinates (m) or Latitude/Longitude:           
Northing:             
Easting:          
Zone:          

Latitude:              
Longitude:          


Section 2     Legal Owner
Section 3     Operator (if different from owner)
Name:          
Name:          
Mailing Address:          
Mailing Address:          
City:          
State:           
Zip:          
City:          
State:           
Zip:          
Telephone #:          
Telephone #:          
E-Mail Address:          
E-Mail Address:          


Section 4     Designated Agent (for service of process)
Section 5     Billing Contact Person (if different from owner)
Name:          
Name:          
Mailing Address:          
Mailing Address:          
City           
State:           
Zip:          
City:          
State:          
Zip:          
Telephone #:          
Telephone #:          
E-Mail Address:          
E-Mail Address:          


Section 6     Application Contact
Name:          
Mailing Address:          
City:          
State:          
Zip:          

Telephone:          

E-Mail Address:          


Section 7    Desired Process Method     (Check only one  -  see 18 AAC 50.542(a) for process descriptions and restrictions)
             Fast track for a permit classification under 
       18 AAC 50.502 [18 AAC 50.542(b)]
   Public comment [18 AAC 50.542(d)]




Section 8  Source Classification(s) (Check all that apply)
Section 9   Modification Classification(s) (Check all that apply)

[18 AAC 50.502(b)]
[18 AAC 50.502(c)(3)]
     Asphalt Plant  [> 5 ton per hour]
   NOx Increase > 10 tpy	[and existing PTE > 40 tpy]
     Thermal Soil Remediation Unit  [> 5 ton per hour]
   SO2 Increase > 10 tpy	[and existing PTE > 40 tpy]
     Rock Crusher  [> 5 ton per hour]
   PM-10  Increase > 10 tpy	[and existing PTE > 15 tpy]
     Incinerator(s)  [total rated capacity > 1000 lb/hour]
   PM-2.5 Increase > 10 tpy	[and existing PTE > 10 tpy]
     Coal Preparation Plant
   CO  Increase > 100 tpy	[and existing PTE > 100 tpy
     Port of Anchorage Facility
                     in a nonattainment area]


    If you checked any of the above, is (are) the emission 
[18 AAC 50.502(c)(4)]
    unit(s)    new,   relocated*, or   existing? 
   NOx Increase > 40 tpy	[and existing PTE <= 40 tpy]
    
   SO2 Increase > 40 tpy	[and existing PTE <= 40 tpy] 

   PM-10 Increase > 15 tpy	[and existing PTE <= 15 tpy]
[18 AAC 50.502(c)(1)]
   PM-2.5 Increase > 10 tpy	[and existing PTE <= 10 tpy]
New or relocated* stationary source with potential emissions greater than:
   CO Increase > 100 tpy         [and Existing PTE <= 100 tpy 
	in a nonattainment area]

                                                     
   40 tons per year (tpy) NOx 
Basis for calculating modification:
   40 tpy SO2  
   Projected actual emissions minus baseline actual emissions
   15 tpy PM-10 
   10 tpy PM-2.5
   New potential emissions minus existing potential emissions
   0.6 tpy lead 

   100 tpy CO in a nonattainment area 


Section 10     Permit Action Request (Check all that apply)
[18 AAC 50.502(c)(2)]

Construction or relocation* of a:
[18 AAC 50.508]
     Portable oil and gas operation
   Establish Plant-wide Applicability Limitation (PAL)
     > 10 MMBtu/hr fuel burning equipment in a SO2 
   Establish emission reductions to offset nonattainment pollutant 
    special protection area 
   Owner Requested Limit* (ORL)
*     Relocation does NOT include moving equipment
   from one place to another within your current 
   stationary source boundary.

   Revise or Rescind Title I Permit Conditions *
   Permit Number:             Condition No.           
   Date:           
   
 *Which to use?  See http://www.dec.state.ak.us/air/ap/docs/orlrtc.pdf

Section 11     Existing Permits and Limits



For an existing stationary source, do you have an existing: 
(Check all that apply)
           
   Air quality permit        Number(s)*:             

                                      

                                      

                                      
                            
      
   Owner Requested Limit(s)	Permit Number(s):	          

   Pre-Approved Emission Limit	(PAEL) Number(s)**:	          



* All active construction, Title V, and minor permit numbers.

**Optional.  Please provide this number if possible.  
   
http://dec.alaska.gov/Applications/Air/airtoolsweb/ 




Section 12     Project Description

Provide a short narrative describing the project.  Discuss the purpose for conducting this project, what emission units/activities will be added/modified under this project (i.e., project scope), and the project timeline.  If the project is a modification to an existing stationary source, describe how this project will affect the existing process.  Include any other discussion that may assist the Department in understanding your project or processing your application.  Include a schedule of construction. 


Please use additional copies of this sheet if necessary.


          




















































Section 12    Project Description Continued
For PALs under Section 10 of this application, include the information listed in 40 C.F.R. 52.21(aa)(3), adopted by reference in 18 AAC 50.040 [18 AAC 50.540(h)].

          
For a limit to establish offsetting emissions under Section 10 of this application, specify the physical or operational limitations necessary to provide actual emission reductions of the nonattainment air pollutant; including [18 AAC 50.540(i)]: 
 
 A calculation of the expected reduction in actual emissions; and  
   
             










 The emission limitation representing that quantity of emission reduction.
   
             







Section 12    Project Description Continued
For ORLs under Section 10 of this application [18 AAC 50.540(j)], include: 
 
 A description of each proposed limit, including for each air pollutant a calculation of the effect the limit will have on the stationary source's potential to emit and the allowable emissions [18 AAC 50.225(b)(4)]; 
 
           
 A description of a verifiable method to attain and maintain each limit, including monitoring and recordkeeping requirements [18 AAC 50.225(b)(5)];
 
           
 Citation to each requirement that the person seeks to avoid, including an explanation of why the requirement would apply in the absence of the limit and how the limit allows the person to avoid the requirement [18 AAC 50.225(b)(6)];
 
           
 A statement that the owner or operator of the stationary source will be able to comply with each limit [18 AAC 50.225(b)(8)]; 
 
           
   

Section 12    Project Description Continued
For revising or rescinding Title I permit conditions under Section 10 of this application [18 AAC 50.540(k)], include: 
 
 An explanation of why the permit term or condition should be revised or rescinded [18 AAC 50.540(k)(2)];
 
           
 The effect of revising or revoking the permit term or condition on [18 AAC 50. 540 (k)(3)]:
 Emissions; 
                
 Other permit terms;
                
 The underlying ambient demonstration, if any;
                
 Compliance monitoring; and
                
      
      
      
      
 For revising a condition that allows avoidance of a permit classification, the information required for that type of permit, unless the revised condition would also allow the owner or operator to avoid the classification. [18 AAC 50.540(k)(4)]
 
           

Section 13     Other Application Material
The information listed below must be included in your air quality control minor permit application. Note: These must be attached in order for your application to be complete.

If required to submit an analysis of ambient air quality under 18 AAC 50.540(c)(2), or if otherwise requested by the Department:  

  Attached are maps, plans, and/or aerial photographs as necessary to show the locations and distances of 
       emissions units, buildings, emitting activities and boundaries of the associated with the stationary source, and
       nearby or adjacent residences, roads, other occupied structures and general topography within 15 kilometers.
      (Indicate compass direction and scale on each.)
      
  Attached is a document (e.g., spreadsheet) showing coordinates and elevations of each modeled unit, along with parameters necessary to characterize each unit for dispersion modeling.

  Attached is an electronic copy of all modeling files.



Section 14     Certification
This certification applies to the Air Quality Control Minor Permit Application for the  
          
submitted to the Department on:
          .
                                                                            (Stationary Source Name)

Type of Application
     Initial Application
     Change to Initial Application

The application is NOT complete unless the certification of truth, accuracy, and completeness on this form bears the signature of a Responsible Official. Responsible Official is defined in 18 AAC 50.990. 
(18 AAC 50.205)

              CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESS

"Based on information and belief formed after reasonable inquiry, I certify that the statements and information in and attached to this document are true, accurate, and complete."


Signature: 
Date: 

Printed Name:            
Title:          


Section 15     Attachments

 Attachments Included.
List attachments:
          


          


          


          


          


          


Section 16     Mailing Address
Submit the minor permit application to the Permit Intake Clerk in the Department's Anchorage office.  Submitting to a different office will delay processing. The mailing address and phone number for the Anchorage office is:


Permit Intake Clerk 
Alaska Department of Environmental Conservation 
Air Permit Program
555 Cordova Street
Anchorage, Alaska 99501
(907) 269-6881


