5900 Certification of Truth, Accuracy, and Completeness (CTAC

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OMB No. 2060-0336, Approval Expires 06/30/2010

Federal Operating Permit Program (40 CFR Part 71)

CERTIFICATION OF TRUTH, ACURACY, AND COMPLETENESS (CTAC)

This form must be completed, signed by the “Responsible Official” designated for the facility or emission unit, and sent with each submission of documents (i.e., application forms, updates to applications, reports, or any information required by a part 71 permit).

A. Responsible Official

Name: (Last) _________________________ (First) _______________________ (MI) ____

Title ___________________________________________________

Street or P.O. Box ________________________________________

City ___________________________________ State _____ ZIP _________ - _____

Telephone (____) _____ - _________ Ext. _______ Facsimile (____) _____ - __________

B. Certification of Truth, Accuracy and Completeness (to be signed by the responsible official)

I certify under penalty of law, 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 (typed) _____________________________________ Date: _____ /_____ /_________

INSTRUCTIONS FOR CTAC

CERTIFICATION OF TRUTH, ACURACY, and COMPLETENESS

This form is for the responsible official to certify that submitted documents (i.e., permit applications, updates to application, reports, and any other information required to be submitted as a condition of a permit) are true, accurate, and complete.

This form should be completed and submitted with each set of documents sent to the permitting authority. It may be used at time of initial application, at each step of a phased application submittal, for application updates, as well as to accompany routine submittals required as a term or condition of a permit.

Section A - Title V permit applications must be signed by a responsible official. The definition of responsible official can be found at ' 70.2.

Section B - The responsible official must sign and date the certification of truth, accuracy and completeness. This should be done after all application forms are complete and the responsible official has reviewed the information. Normally this would be the last form completed before the package of forms is mailed to the permitting authority.

EPA Form 5900-02