Form 7630-9 Non-Title V Operating Permit Application Form

Form Approved OMB 2060-0558 Approval Expires 5/31/2011

U. S. Environmental Protection Agency
Region 10 Federal Air Rules for Reservations, 40 CFR 49.139

Non-Title V Operating Permit Application Form
Request for Federally-Enforceable Limitation
Complete all sections of this form. For additional guidance, see the Non-Title V Operating Permit Application
Form Instructions. Electronic copies of forms and guidance can be found at www.epa.gov/region10/farr
Mail completed application forms to:

Non-Title V Operating Permit Coordinator
U.S. EPA, Region 10
AWT-107
1200 Sixth Avenue
Seattle, WA 98101

A. General Information
1.

Name of Air Pollution Source: __________________________________________________________________
Nature of the Business: _______________________________________________________________________
Primary SIC Code: ________________ Other SIC Codes: _______________________________________
Street Address: ______________________________________________________________________________
Telephone Number: ______________________ Source Facsimile Number: _____________________________

2.

Local Individual Responsible for Compliance Name: _________________________________________________
Mailing Address: _____________________________________________________________________________
Telephone Number: ___________________________ Facsimile Number: ______________________________

3.

Individual Authorized to Receive Requests for Data & Information Name: ________________________________
Mailing Address: ______________________________________________________________________________

4.

Owner Name: _________________________________________________________________________________
Mailing Address: ______________________________________________________________________________

Telep

hone Number: ____________________________________________________________________________

5. Ope rator Name (if different from Owner): ______________________________________________________________
Mailing Address: ______________________________________________________________________________
Telep

hone Number: ____________________________________________________________________________

EPA Form 7630-9

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Form Approved OMB 2060-0558 Approval Expires 5/31/2011

B. Limitation Request
For each air pollutant and for all emissions units and air pollutant-generating activities to be covered by a limitation,
attach the following:
1.

The proposed limitation and a description of its effect on actual emissions or the potential to emit.

2.

The proposed testing, monitoring, recordkeeping and reporting requirements to be used to demonstrate and assure
compliance with the proposed limitation.

3.

A description of the production processes and a related process flow chart.

4.

A list of emission units and air pollution-generating activities.

5.

The type and quantity of fuels and/or raw materials used.

6.

A description and estimated efficiency of air pollution control equipment under present or anticipated operating
conditions.

7.

Estimates of the current actual emissions and current potential to emit, including all calculations for the estimates.

8.

Estimates of the allowable emissions and/or potential to emit that would result from compliance with the proposed
limitation, including all calculations for the estimates.

C. Certification of Truth, Accuracy and Completeness
The Owner or Operator (listed above) must sign this statement before submittal of this application form.
I certify that, based on information and belief formed after reasonable inquiry, the statements and
information in and attached to this form are true, accurate and complete.
Owner

or Operator (circle one) Name: ______________________________________________________________

Owner or Operator Signature: _____________________________________________ Date: _______________

The public reporting and recordkeeping burden for this collection of information is estimated at 88.33
hours per response on average. 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.

EPA Form 7630-9

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