7630-5 Report Of Change Of Ownership

Form Approved OMB 2060-0558 Approval Expires 11/30/2007

U NITED STATES ENVIRONMENTAL PROTECTION AGENCY

REGION 10 FEDERAL AIR RULES FOR INDIAN RESERVATIONS

REPORT OF CHANGE OF OWNERSHIP

Applicability: Air pollution sources regulated by 40 Code of Federal Regulations Part 49.138.

Report change of ownership within 90 days after the effective date of change.

INSTRUCTIONS: Complete applicable parts of Sections A, B, C and D.

A. GENERAL INFORMATION

Identifying Information

Previous Source (Facility) Name_________________________________________________

Previous Owner’s Name ________________________________________________________

New Source (Facility) Name _____________________________________________________

Air Quality Operating Permit No. (if applicable) _____________________________________

Nature of the Business_________________________________________________________

Telephone (_____) _______-________ Facsimile (_____)______-________

Source Physical Address: Street ________________________________________

City______________________ County_______________ State ________ ZIP _________-________

Indian Reservation Name______________________________________________

Compliance Contact Person ______________________________ Title__________________________

(Local Person responsible for source compliance with this rule)

Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________

Contact Person Mailing Address: Street (or PO Box #) __________________________________

City______________________ County______________ State ________ ZIP _________-________

e.mail address _____________________________

A. GENERAL INFORMATION Cont.

Owner’s Name___________________________________________________

New Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________

Owner Mailing Address: Street ( or PO Box #) _______________________________

City______________________ County_________________ State ________ ZIP _________-________

e.mail address ______________________________

Contact ____________________Title__________________________

(Person authorized to receive requests for data and information)

Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________

Contact Person Mailing Address: Street (or PO Box #) ________________________________________

City______________________ County___________________ State ________ ZIP _________-________

e.mail address _______________________________

Operator’s Name____________________________________________(If different from owner)

New Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________

Operator Mailing Address: Street ( or PO Box #) _______________________________

City______________________ County_________________ State ________ ZIP _________-________

e.mail address ______________________________

Contact ____________________Title__________________________

(Person authorized to receive requests for data and information)

Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________

Contact Person Mailing Address: Street (or PO Box #) ________________________________________

City______________________ County___________________ State ________ ZIP _________-________

e.mail address _______________________________

Effective Date of Change of Ownership

Date.____/____/________

B. ATTACHMENTS

Include any of the following information as attachments to this form that requires updating as a result of the change of ownership

• Process flow chart identifying all processing, combustion, handling, storage, and emission control equipment

• Narrative description of the production processes and air pollution control equipment

• List of all emission units and air pollution generating activities; include model and serial numbers for portable equipment

• Plot Plan

  • Location of all emission units and air pollution generating activities

  • Property lines for the air pollution source

  • Elevation above grade for each emission release point

  • Distance and direction to nearest residential or commercial property

• Type and quantity of fuels, including sulfur content of fuels, used on a daily, annual and maximum hourly basis

• Type and quantity of raw materials used or final product produced on a daily, annual and maximum hourly basis

• Typical operating schedule, including number of hours per day, number of days per week and number of weeks per year

• List of estimated efficiency of air pollution control equipment under present or anticipated operating conditions

• Estimates of the total actual emissions from the air pollution source for the following air pollutants: particulate matter, PM10, PM2.5, sulfur oxides (SOx), nitrogen oxides (NOx), carbon monoxide (CO), volatile organic compound (VOC), lead (Pb) and lead compounds, ammonia (NH3), fluorides (gaseous and particulate), sulfuric acid mist (H2SO4), hydrogen sulfide (H2S), total reduced sulfur (TRS) and reduced sulfur compounds, including all calculations for the estimates

• Other (provide details)

Confidential Treatment of Information

You may assert a business confidentiality claim covering any portion of the submitted information as provided in 40 C.F.R. part 2, subpart B. Please submit any information you claim as confidential business information separately, along with your claim of confidentiality. Note that emissions data and information necessary to determine emissions is not entitled to confidential treatment. Failure to assert a claim in the manner described in 40 C.F.R. part 2, subpart B allows the submitted information to be released to the public without further notice. Information subject to a business confidentiality claim may be disclosed by EPA only to the extent set forth in the above-cited regulations

C. TABLE OF ANNUAL EMISSIONS

The following table should be completed by inserting estimates of the total actual emissions in tons/year for all pollutants contained in your worksheet stated above.

Pollutant	Total Emissions
PM
PM10
PM 2.5
SOx
NOx
CO
VOC
Pb
NH3
Fluorides
H2SO4
H2S
TRS
RSC

Definition of acronyms

PM Particulate Matter

PM10 Particulate Matter less than 10 microns in size

PM2.5 Particulate Matter less than 2.5 microns in size

SOx Sulfur Oxides

NOx Nitrogen Oxides

CO Carbon Monoxide

VOC Volatile Organic Compound

Pb Lead and lead compounds

NH3 Ammonia

Fluorides Gaseous and particulates

H2SO4 Sulfuric Acid Mist

H2S Hydrogen Sulfide

TRS Total Reduced Sulfur

RSC Reduced Sulfur Compounds

D. OWNER OR OPERATOR’S CERTIFICATION OF TRUTH, ACCURACY AND COMPLETENESS

Certifying Official Information: Identify the certifying official and provide contact information.

Name: (Last)____________________(First)__________________(Middle)_____________

Title______________________________________________________________________

Street or P.O. Box______________________________________________________

City____________________County_________________State______________ZIP________-__________

Telephone (____)_____-__________ Ext._______ Facsimile (____)________-___________

e.mail address ___________________________________________

Certification of Truth, Accuracy and Completeness: The Certifying Official must sign this statement after the form is completed.

I certify that, based on information and belief formed after reasonable inquiry, the statements and information contained in these documents are true, accurate and complete.

Name (signed)________________________________________________________

Name (printed or typed)_______________________________________Date____/____/_______

Return completed forms and attachments to:

EPA Region 10 (OAWT)

FARR Registration Coordinator

Office of Air Waste and Toxics

1200 Sixth Avenue

Seattle, WA 98101

The public reporting and recordkeeping burden for this collection of information is estimated at eight hours for a facility which is not considered a complex operation, and up to 40 hours for a moderately complex operation. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, US Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number 2060-0558 in any correspondence. Do not send the completed form to this address.

FARR REGISTRATION APPLICATION INSTRUCTIONS

GENERAL INFORMATION

Identifying Information

FACILITY

Enter the name and the correct street address or other physical location of the facility (e.g. Acme Road or Building 3, XYZ Industrial Park) together with telephone and facsimile numbers.

Provide a brief description of the nature of the business conducted by the facility.

Provide name of the Indian Reservation on which the facility is located.

Provide name and contact information for the facility contact person responsible for source compliance with this rule.

OWNER / OPERATOR

Enter the name of the new owner and operator of the facility for which this application is being prepared. For individual owners, list the full name (last, middle initial, first). For multiple ownership where no legal business partnership exists, provide the name and mailing address, if different, of each individual owner using a backslash (\) to separate data for each owner. For corporations, include divisions or subsidiary name, if any. Enter the complete mailing address of the new owner and operator.

Provide name and contact information for the contact person authorized to receive requests for data and information.

PROCEDURE FOR ESTIMATING EMISSIONS

The initial registration and annual registration must include an estimate of actual emissions taking into account equipment, operating conditions, and air pollution control measures. For an existing air pollution source that operated during the calendar year preceding the initial registration or annual registration submittal, the actual emissions are the actual rate of emissions for the preceding calendar year and must be calculated using the actual operating hours, production rates, in-place control equipment, and types of materials processed, stored, or combusted during the preceding calendar year. For a new air pollution source that is submitting its initial registration, the actual emissions are the estimated actual rate of emissions for the current calendar year. The emission estimates must be based upon actual test data or, in the absence of such data, upon procedures acceptable to the Regional Administrator. Any emission estimates submitted to the Regional Administrator must be verifiable using currently accepted engineering criteria. The following procedures are generally acceptable for estimating emissions from air pollution sources:

(i) Source-specific emission tests;

(ii) Mass balance calculations;

(iii) Published, verifiable emission factors that are applicable to the source;

(iv) Other engineering calculations; or

(v) Other procedures to estimate emissions specifically approved by the Regional Administrator.

EPA Form 7630-5 Page 1 of 6