Form 7620-16 Account Certificate of Representation

United States
Environmental Protection Agency

OMB No. 2060-0445

Account Certificate of Representation
This form is required to establish an Authorized Account Representative for compliance accounts under
the NOx Budget Trading Program. For more information, see instructions on the reverse side of the form.
This submission is: ~ New

STEP 1
Identify the budget source(s)
by plant name, State, and, if
applicable, ORISPL code.

STEP 2
Enter requested
information for the
Authorized Account
Representative (AAR).

~ Revised
Check this box if you are also the Designated Representative for this plant under the Acid Rain Program: ~
Plant Name

State

Name
Address

AAR ID Number (if known)

Phone Number

ORIS Code

Fax Number

E-mail Address (if available)

STEP 3
Enter requested
Name
information for the
Alternate Authorized Account
Phone Number
Representative,
if applicable.

AAR ID Number (if known)

Fax Number

E-mail Address (if available)

STEP 4
Provide the name of
every owner and
operator of the
budget sources at
the plant. Identify
the budget sources
they own and/or
operate by boiler ID#.

Name

~ Owner

~ Operator

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

~ Owner

~ Operator

Name
ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

~ Owner

~ Operator

Name
ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

ID#

Account Certificate of
Representation - Page 2

Plant Name (from Step 1)

STEP 5
Read the certification,
sign and date.

I certify that I was selected as the NOx authorized account representative or alternate NOx authorized
account representative, as applicable, by an agreement binding on the owners and operators of the NOx
Budget source and each NOx Budget unit at the source. I certify that I have all the necessary authority to
carry out my duties and responsibilities under the NOx Budget Trading Program on behalf of the owners
and operators of the NOx Budget source and of each NOx Budget unit at the source and that each such
owner and operator shall be fully bound by my representations, actions, inactions, or submissions and by
any decision or order issued to me by the permitting authority, the Administrator, or a court regarding the
source or unit.
I am authorized to make this submission on behalf of the owners and operators of the NOx Budget
sources or NOx Budget units for which the submission is made I certify under penalty of law that I have
personally examined, and am familiar with, the statements and information submitted in this document all
its attachments. Based on my inquiry of those individuals with primary responsibility for obtaining the
information, I certify that the statements and information are to the best of my knowledge and belief true,
accurate, and complete. I am aware that there are significant penalties for submitting false statements and
information or omitting required statements and information, including the possibility of fine or
imprisonment.

Signature (Authorized Account Representative)

Date

Signature (Alternate Authorized Account Representative)

Date

INSTRUCTIONS
Under the state regulations to implement the NOx Budget Trading Program, the owners and operators for each budget source must designate a representative,
and may designate an alternate, to act on their behalf. The owners and operators should choose the representative through a process that ensures that all owners
and operators have notice regarding the selection. All budget sources at a plant must have the same Authorized Account Representative. The Authorized Account
Representative is responsible for all submissions and allowance transactions relating to the budget sources at that plant. The Authorized Account Representative
and the Alternate Authorized Account Representative are liable for acts or omissions within the scope of their responsibilities under the NOx Budget Trading
Program. EPA will not record an allowance transaction until it has received a complete Account Certificate of Representation.

Please type or print. If more space is needed, photocopy the
first page. Indicate the page order and total number of pages
(e.g., 1 of 4, 2 of 4, etc.). Note: An Account Certificate of
Representation amending an earlier submission supersedes
the earlier submission in its entirety. A revised Account
Certificate of Representation must therefore be complete,
including signature and dating by the Authorized Account
Representative (and the Alternate, if applicable).
Submit one Account Certificate of Representation form with
original signatures. Remember that the Authorized Account
Representative should notify each owner and operator of all
NOx Budget Program submissions.
For assistance, call the EPA’s Clean Air Markets Division
Hotline at (202) 343-9620.
STEP 1: If any budget source at the plant is affected by the
Acid Rain Program, the ORISPL code is embedded in the
first six digits of the unit account number for that
source
under the Acid Rain Program. If there are not any budget
sources at the plant affected by the Acid Rain Program, a
budget source should use the plant or
facility code
registered with the Department of Energy (DOE) to obtain an
ORISPL code. (For utilities reporting on the EIA-767, -860,
and -861, the plant code would be used as the ORISPL code.
For nonutilities reporting on the EIA-867, the facility code
would be used as the (ORISPL code). If the budget source
does not report to DOE, and therefore does not have an
ORISPL code, the budget source should call the Acid Rain
Program Hotline for assistance.
STEP 2: The Authorized Account Representative must
be a natural person and cannot be a company. Please enter the
firm name and address as it should appear on all
correspondence.
EPA Form 7620-16
Representative must rely on the Authorized Account
Representative to forward information
mailed by EPA.

STEP 4 The owners and operators may be companies or natural
persons. Identify each budget source at the plant that is owned or
operated by the named party by providing the unit identification
number for the budget source. If a budget source is affected by the
Acid Rain Program, the source should
determine an appropriate ID# that it will use for all NOx Budget
Trading Program purposes. This ID# must be six digits or less.
STEP 5 Note the certification statement.
SUBMISSION INSTRUCTIONS:
Submit this form prior to submission of the monitoring plan for the
NOx Budget Trading Program. This form must be submitted before
participating in transfers of allowances.
Submit a revised Account Certificate of Representation when any
information in the existing Account Certificate of Representation
changes.
Mailing Instructions
Mail this form to EPA at one of the following addresses:
U.S. EPA
NOx Budget Trading Program (6204J)
for regular or certified mail:
for overnight mail:
1200 Pennsylvania Ave, NW
1310 L Street, NW
Washington, DC 20460
Washington, DC 20005
Phone: 202-343-9620

Paperwork Burden Estimate
The public reporting and record keeping burden for this collection of information is estimated to average30 hours per response . Burden means
the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to or for a
Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the
purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing
information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to
respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise
disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number.
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,
U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Ave., NW., Washington, D.C. 20460. Include the OMB control number
in any correspondence. Do not send the completed form to this address.