5900-343 Notification of Coverage under the Air Quality Permit by

EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

United States Environmental Protection Agency
Air Quality Permit by Rule for New or Modified True Minor Sources of
Air Pollution in Indian Country
https://www.epa.gov/tribal-air/tribal-minor-new-source-review

Notification of Coverage under the Air Quality Permit by Rule for New or Modified
True Minor Source Gasoline Dispensing Facilities in Indian Country
Last Modified: January 4, 2017
Version 1.0

This Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline
Dispensing Facilities in Indian Country applies to the construction of new, true minor source gasoline dispensing
facilities or the modification of existing, true minor source gasoline dispensing facilities in Indian country. It applies
only to facilities that dispense greater than 4,000,000 gallons of gasoline in National Ambient Air Quality Standard
(NAAQS) ozone attainment, unclassifiable or attainment/unclassifiable areas, or dispense greater than 2,100,000
gallons of gasoline annually in NAAQS ozone nonattainment areas. A gasoline dispensing facility is any stationary
facility which dispenses gasoline into the fuel tank of a motor vehicle, nonroad vehicle or equipment, including a
nonroad vehicle or nonroad engine used solely for competition.
This Permit by Rule is not available for use by gasoline dispensing facilities
within the geographic boundaries of the State of California.
You qualify to submit a Notification of Coverage under the Permit by Rule if you meet all of the
following criteria:
• You plan to construct a true minor source gasoline dispensing facility that dispenses gasoline for resale or
non-resale purposes or you plan to modify an existing, true minor source gasoline dispensing facility that
dispenses gasoline for resale or non-resale purposes;
• Your new or modified true minor source gasoline dispensing facility is located within Indian country;
• Your facility has a potential to emit (PTE) less than the New Source Review (NSR) major source thresholds;
• If located in a serious, severe or extreme ozone nonattainment area, after the proposed construction or
modification project, your facility is projected to dispense less than 8,000,000 gallons of fuel per year based
on a 12-month rolling total;
• If located in an attainment, unclassifiable or attainment/unclassifiable ozone area or a marginal/moderate
nonattainment ozone area, after the proposed construction or modification project, your facility is
projected to dispense less than 25,000,000 gallons of fuel per year based on a 12-month rolling total;
• If located in an ozone nonattainment area, after the proposed construction or modification project, your
facility is projected to dispense more than 2,100,000 gallons of fuel over a consecutive 12-month period;
• If located in an attainment, unclassifiable or attainment/unclassifiable area for ozone, after the proposed
construction or modification project, your facility is projected to dispense more than 4,000,000 gallons of
fuel over a consecutive 12-month period;
• You demonstrate, and obtain confirmation from the U.S. Environmental Protection Agency (EPA), that you
have followed the screening process the EPA has provided with respect to the protection of species that are
federally-listed as threatened or endangered under the Endangered Species Act (ESA) or of habitat that is
federally-designated as “critical habitat” under the ESA; and

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

• You demonstrate, and obtain written confirmation from the EPA, that you followed the screening process to
address any effects to historic properties eligible for protection under the National Historic Preservation Act
(NHPA).
The reviewing authority retains discretion to terminate your coverage under the Permit by Rule and require a sourcespecific permit even if the above criteria are met. Reasons the reviewing authority may terminate a permitted source’s
coverage under the Permit by Rule include:
1. The permittee is not in compliance with the provisions of the Permit by Rule;
2. The reviewing authority determines that the emissions resulting from the construction or modification of the
permitted source significantly contribute to NAAQS violations, which are not adequately addressed by the
requirements in the Permit by Rule;
3. The reviewing authority has reason to believe that the permittee obtained coverage under the Permit by Rule by
fraud or misrepresentation; or
4. The permittee failed to disclose a material fact required by the Notification of Coverage or the regulations
applicable to the permitted source of which the applicant had or should have had knowledge at the time the
permittee submitted the Notification of Coverage.
More Information
Information on the definition of a “modification” and “PTE” can be found at 40 CFR 49.152(d) and in the
“Instructions” document. Additional information on the applicability of the Federal Indian Country Minor NSR Rule
can be found at 40 CFR 49.153.
Information on the ozone attainment status of the area where your facility is located can be found at:
https://www.epa.gov/green-book. You may also contact your reviewing authority for information on the area’s
attainment status.
Sources eligible for the Air Quality Permit by Rule for New or Modified True Gasoline Dispensing Facilities may also be
subject to federal standards under 40 CFR 63 Subpart CCCCCC, National Emission Standards for Gasoline Dispensing
Facilities, 40 CFR 60 Subpart IIII – Standards of Performance for Stationary Compression Ignition Internal Combustion
Engines, 40 CFR 60 Subpart JJJJ – Standards of Performance for Stationary Spark Ignition Internal Combustion Engines,
and 40 CFR 63 Subpart ZZZZ– National Emission Standards for Hazardous Air Pollutants for Stationary Reciprocating
Internal Combustion Engines. The conditions applicable to sources seeking coverage under this Permit by Rule are
intended to be generally consistent with the requirements in 40 CFR 63 Subpart CCCCCC, 40 CFR 60 Subpart IIII, 40 CFR
60 Subpart JJJJ, and 40 CFR 63 Subpart ZZZZ. However, compliance with the applicable requirements in 40 CFR part 63,
Subpart CCCCCC is required independent of the conditions in the Permit by Rule, and not all requirements applicable
under Subpart CCCCCC are necessarily included in the Permit by Rule. The Background Document for the Permit by Rule
identifies the specific requirements in Subparts CCCCCC, IIII, JJJJ, and ZZZZ that are intended to be included in the Permit
by Rule. The EPA’s brochure for Subpart CCCCCC is available here: http://www.epa.gov/ttn/atw/area/gdfb.pdf.

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Instructions
Step 1: Notify your reviewing authority, including providing appropriate documentation, that you (1) meet one of the
criteria listed in the EPA’s screening process for the protection of any and all species that are federally-listed as
threatened or endangered under the ESA or of habitat that is federally-designated as “critical habitat” under the ESA;
and (2) satisfy the EPA’s screening process for the NHPA. You must obtain written confirmation from the EPA that the
threatened or endangered species and historic property screening procedures have been satisfied prior to submitting
your Notification of Coverage under the Permit by Rule.

Step 2: After receiving notification that you have successfully met the requirements of Step 1, complete all sections of
the Notification of Coverage under the Permit by Rule (i.e., pages 4 – 10). If you have questions, please contact the
reviewing authority.
Step 3: Certify that your existing or proposed facility is/will be in compliance with the applicable requirements as stated
in 40 CFR 49.164 and submit a copy of this notification to the reviewing authority and to the tribe in the area where the
source is located/locating. Submittal of this Notification of Coverage form also satisfies the requirement that minor
sources in Indian country register with the EPA.
After you submit the Notification of Coverage under the Permit by Rule to the reviewing authority:
• You may commence construction of your new source or modification of your existing source under the Permit by
Rule.
• Your reviewing authority may request additional information from you in order to verify you are eligible for the
Permit by Rule.
The public reporting and recordkeeping burden for this collection of information is estimated to average 28 hours per
response. Applicants are welcome to send comments on the EPA’s need for the information in this application, 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 (2822T), 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.

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

United States Environmental Protection Agency
Air Quality Permit by Rule for New or Modified True Minor Sources
of Air Pollution in Indian Country
https://www.epa.gov/tribal-air/tribal-minor-new-source-review

Notification of Coverage under the Air Quality Permit by Rule for New or Modified
True Minor Source Gasoline Dispensing Facilities in Indian Country
Last Modified: January 4, 2017
Version 1.0

Prior to construction or modification, complete this application and submit it to your reviewing
authority. A list of reviewing authorities, their areas of coverage, and contact information can be found in
Attachment D to the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities
in Indian Country or visit: https://www.epa.gov/tribal-air/5-source-categories-gasoline-dispensing-facilities-final-rule.
For questions regarding this notification please contact your reviewing authority.
For instructions on completing this application please see the document “Instructions for Notification of Coverage
under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian
Country.”

Section 1: Contact Information
1. Business Name:

2. Date:

3. Site Address:

4. County:

5. Name of Operator at Site (if different from owner):

6. Phone of Operator or Contact at Site (if different from
owner):

7. Owner:

8. Telephone Number of Owner:

9. Owner’s Mailing Address:

10. Send all correspondence regarding this application
to:
Company Name:
c/o:
Address:

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

11. Authorized contact regarding this permit application:
Name:
Title:
Phone:

Email:
FAX:

Section 2: Facility and Technical Information for the Notification of Coverage under the Air
Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in
Indian Country
12. This notification is for:
New retail gasoline dispensing facility (please describe the proposed new source).

New non-retail gasoline dispensing facility (please describe the proposed new source).

Modification of an existing gasoline dispensing facility. Please describe the modification below. The definition of
“modification” can be found at 40 CFR 49.152(d), and in the “Instructions” document available for completing this
notification form.

13. North American Industry Classification System/Standard Industrial Classification Code and/or description for the
facility:

14. Will your new or modified facility be located in an ozone nonattainment area? Information on the ozone
attainment status of the area where your facility is located can be found at: https://www.epa.gov/greenbook.
Yes

No

If you answered ‘Yes,’ specify the classification of the ozone nonattainment area:
Marginal

Moderate

Notification of Coverage: Gasoline Dispensing Facilities
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Serious

Severe

Extreme

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

15. Will the PTE of your new facility, or the increase in potential emissions from your modified existing facility, be
equal to or above the applicable minor NSR thresholds listed below for ANY of the listed pollutants, both in tons
per year (tpy)? Emissions from your facility may be calculated using the PTE calculator available online at:
https://www.epa.gov/tribal-air/5-source-categories-gasoline-dispensing-facilities-final-rule. Be sure to include all
new or modified emission units at your facility.
Pollutant

Attainment Area

Nonattainment Area

CO

10 tpy

5 tpy

Particulate Matter (PM)
Particulate Matter
(PM10)
Particulate Matter
(PM2.5)
Sulfur Dioxide (SO2)

10 tpy

5 tpy

5 tpy

1 tpy

3 tpy

0.6 tpy

10 tpy

5 tpy

Nitrogen Oxides (NOX)
Volatile Organic
Compounds (VOC)

10 tpy

5 tpy

5 tpy

2 tpy

Yes

No

If you answered ‘No’, your source is exempt from the minor NSR program. Please contact your reviewing authority
to confirm that your facility will not need a permit. If you answered ‘Yes’, continue on to the next question.
16. If located in an attainment, attainment/unclassifiable or unclassifiable area, will the PTE of your facility be
less than 250 tpy for PM, PM10, PM2.5, VOC, NOX, CO, and SO2? Be sure to include all existing, new, and
modified emission units at your facility.
Yes

No

If you answered ‘No,’ your source does not qualify for the Permit by Rule. Please contact your reviewing
authority to apply for a site-specific permit. If you answered ‘Yes,’ continue on to the next question.

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

17. If located in a nonattainment area, will the PTE of your facility for the particular nonattainment pollutant
be less than the NSR major source thresholds below for ALL pollutants? Be sure to include all existing,
new, and modified emission units at your facility.
Pollutant
Ozone

PM10
CO
SO2, NO2, PM2.5
Yes

Nonattainment Classification

NSR Major Source Threshold

Marginal

100 tpy of VOC or NOX

Moderate

100 tpy of VOC or NOX

Serious

50 tpy of VOC or NOX

Severe

25 tpy of VOC or NOX

Extreme

10 tpy of VOC or NOX

Moderate
Serious
Moderate
Serious

100 tpy
70 tpy
100 tpy
50 tpy

No nonattainment classification

100 tpy

No

N/A - Not located in any nonattainment area

If you answered ‘No,’ your source does not qualify for the Permit by Rule. Please contact your reviewing
authority to apply for a site-specific permit. If you answered ‘Yes’ or ‘N/A,’ continue on to the next question.
18. Do you agree to comply with all requirements of the Permit by Rule as stated in CFR 49.164?
Yes

No

If you answered ‘No,’ your source does not qualify for the Permit by Rule under 40 CFR 49.164 and you must
obtain a site-specific permit from your reviewing authority.
19. Emission Units
Information regarding the existing and planned emission units at your facility is required by 40 CFR 49.154
and 49.160. Please provide the information in the following table for each emission unit at the site that is
or will be owned, leased or operated by the applicant. Examples of potential emission units include
gasoline storage tanks, gasoline pumps and emergency engines.
For each emissions unit, include supporting documentation for the PTE of each unit with your
Notification of Coverage. In addition, for existing emission units, include the most recent actual annual
emissions. See 40 CFR 49.154(a)(2). (For more information on how to calculate actual emissions, go to:
https://www.epa.gov/tribal-air/registration-existing-true-minor-sources-air-pollution-indian-country.) As
needed, please include any other relevant information with your Notification of Coverage.

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

List of Existing and Planned Emission Units (attach additional copies of this table as necessary):

Unit ID#

Description of Equipment and/or
Process (include any input materials or
fuels)

Notification of Coverage: Gasoline Dispensing Facilities
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Maximum Capacity
or Production
Rate

Description of
Pollution Control
Equipment

Operating
Schedule

Existing, New
or Modified
(include
installation
date for
existing)

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Section 3: Information on Completing Screening Processes that Have Been Satisfied Prior to
Submitting a Notification of Coverage under the Air Quality Permit by Rule for New or Modified
True Minor Source Gasoline Dispensing Facilities in Indian Country
20. Threatened or Endangered Species
Have you obtained confirmation from the EPA that you have satisfactorily completed the screening process
for the protection of species that are federally-listed as threatened or endangered under the ESA or of
habitat that is federally-designated as “critical habitat” under the ESA? If you answer ‘No,’ you cannot gain
coverage under this Permit by Rule.
Yes

No

21. Historic Properties
Have you obtained confirmation from the EPA that you have satisfactorily completed the screening process
to determine if the construction, modification or operation of your new or modified true minor source of air
pollutants has the potential to cause effects to historic properties (pursuant to the NHPA)? If you answer
‘No,’ you cannot gain coverage under this Permit by Rule.
Yes

No

Section 4: Additional Information about this Air Quality Permit by Rule for New or Modified True
Minor Source Gasoline Dispensing Facilities in Indian Country
This section provides information on the sizes of sources in terms of emissions that are eligible for the Permit by Rule.
The emission limitations and standards in this Permit by Rule are generally expected to ensure that source-wide
emissions are below the rates shown in the following table:

Pollutant
of
Concern

Serious, Severe or
Extreme Ozone
Nonattainment Areas

Ozone Attainment, Unclassifiable
or Attainment/Unclassifiable
Areas and Moderate or Marginal
Ozone Nonattainment Areas

VOC

7.5 tpy

25 tpy

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EPA Form No. 5900-343
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Applicant’s Statement (to be signed by the applicant)
I certify that this document and all attachments were prepared under my direction or supervision according to a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on
my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.

Name:

(Signature)

Name:

(Print or Type)

_Date:

Title:

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