5900-369 Request for Coverage under the General Air Quality Permi

EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

United States Environmental Protection Agency
General Air Quality Permit for New or Modified Minor Sources of Air
Pollution in Indian Country
http://www.epa.gov/air/tribal/tribalnsr.html

Request for Coverage under the General Air Quality Permit for New or Modified
Minor Source Boilers and Emergency Engines in Indian Country
Last Modified: July 1, 2016
Version 1.0

This Request for Coverage under the General Air Quality Permit for New or Modified Minor Source Boilers and
Emergency Engines in Indian Country applies to the construction of new, true minor source boilers or the modification of
existing, true minor source boilers and emergency engines in Indian country that burn only natural gas or low-sulfur
liquid fuels. This source category includes stationary sources with boilers, process heaters and emergency engines. The
permit also covers emergency engines that may be present at the same facility as a boiler; it can also be used to permit
emergency engines located alone at facilities in Indian country. This permit applies to stationary sources that, after the
proposed construction or modification project, have a combined total maximum heat input capacity for boilers, process
heaters, and emergency engines as described below based on the ozone attainment status. A boiler means an enclosed
device using controlled flame combustion in which water is heated to recover thermal energy in the form of steam
and/or hot water. Emergency stationary internal combustion engines include any stationary internal combustion engine
whose operation is limited to emergency situations and required testing and maintenance.
This permit is available in Indian country for use by true minor and synthetic minor sources.
You qualify to apply for coverage under this General Permit if you meet all of the following criteria:
 You plan to construct a new true or synthetic minor source boiler or emergency engine OR you plan to
modify an existing minor source boiler or emergency engine;
 You are not planning to construct or modify a major source boiler or emergency engine;
 Your new or modified minor source of boilers and/or emergency engines is located within Indian Country;
 You plan to construct or modify boilers, process heaters, and/ or emergency engines that, after construction
or modification, burns only gaseous fuels or low-sulfur (containing no more than 15 parts per million (ppm)
(0.0015 percent) sulfur) liquid fuels;
 Your source has a potential to emit (PTE) less than the major source thresholds for hazardous air pollutants
(HAPs);
 Your new or modified minor source will meet one of the operational limitations summarized in Appendix A;
 You demonstrate that you meet one of the criteria listed in Appendix A with respect to the protection of any
and all 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
 You have completed the screening process in Appendix B to determine if the construction, modification or
operation of your new or modified minor source of air pollutants has the potential to cause effects to historic
properties (pursuant to the National Historic Preservation Act (NHPA)).

EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

This General Air Quality Permit for Boilers and Emergency Engines is not applicable to:





Boilers that burn solid fuels (e.g., wood, wood wastes, coal, solid waste, tires, etc.);
Boilers that burn any liquid fuels other than low-sulfur (containing no more than 15 ppm (0.0015 percent)
sulfur) biodiesel or fuel oil;
Boilers that burn any liquid fuels in boilers and process heaters and are located in an extreme ozone
nonattainment area; or
Boilers that are 100 million British thermal units per hour (MMBtu/hr) or larger.

The reviewing authority retains discretion to terminate your coverage under the General Air Quality Permit for New or
Modified Minor Source Boilers and Emergency Engines and require a source-specific permit even if the above criteria are
met. Reasons the reviewing authority may terminate a permitted source’s coverage under the General Permit include:
1. The permittee is not in compliance with the provisions of the General permit;
2. The reviewing authority determines that the emissions resulting from the construction or modification of the
permitted source significantly contribute to National Ambient Air Quality Standard violations, which are not
adequately addressed by the requirements in the General Permit;
3. The reviewing authority has reason to believe that the permittee obtained coverage under the General Permit
by fraud or misrepresentation; or
4. The permittee failed to disclose a material fact required by the Request for 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 Request for 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 air quality attainment status of the area where your facility is located can be found at:
http://www.epa.gov/airquality/greenbook/. You may also contact your reviewing authority for information on the
area’s attainment status.
Information on any available voluntary consensus standards that can be used as alternatives to the emissions
measurement standards in the General Air Quality Permit for New or Modified Minor Source Boilers and Emergency
Engines can be found in: “Voluntary Consensus Standard Results for General Permits and Permits by Rule for the Indian
Country Minor New Source Review Program; 40 CFR Part 49, Subparts 156(c) and 162,” memorandum from Robin Segall,
Acting Group Leader, Measurement Technology Group, to Laura McKelvey, Community and Tribal Programs Group,
February 7, 2014, http://www.epa.gov/air/tribal/tribalnsr.html.
The reviewing authority retains discretion to deny coverage under a general permit and require a source-specific permit
even if the above criteria are met.
Sources eligible for the General Air Quality Permit for New or Modified Minor Source Boilers and Emergency Engines
may also be subject to federal standards under 40 CFR Part 60, Subpart Db - Standards of Performance for IndustrialCommercial-Institutional Steam Generating Units; 40 CFR Part 60, Subpart Dc - Standards of Performance for Small
Industrial-Commercial-Institutional Steam Generating Units; 40 CFR Part 63, Subpart JJJJJJ - NESHAP for Industrial,
Commercial, and Institutional Boilers Area Sources; 40 CFR 60 Subpart IIII – Standards of Performance for Stationary
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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

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 – NESHAP for Stationary Reciprocating Internal
Combustion Engines. The conditions applicable to sources seeking coverage under this General Permit are intended to
be generally consistent with the requirements in these regulations; however, compliance with the applicable
requirements is required independent of the conditions in the General Permit, and not all requirements applicable
under Subparts Db, Dc, JJJJJJ, IIII, JJJJ and ZZZZ are necessarily included in the General Permit. The Background Document
for the General Permit identifies the specific requirements in these provisions that are intended to be included in the
General Permit.

Instructions
Step 1: Complete all sections of the permit application. If you have questions, please contact the reviewing authority.
Step 2: Submit a copy of this permit application to the reviewing authority and the tribe in the area where the source is
locating.

After you submit the application to the Reviewing Authority:





You may not commence construction until you receive notification of the final decision on your application for
coverage under this General Permit.
Your reviewing authority will act on your permit as expeditiously as possible, and will notify you in writing within
30 days from receipt of your application, if more information is needed. Upon deeming the application complete,
and if any additional information requested by the reviewing authority is received within 15 days of the request,
the reviewing authority will follow the procedures outlined in 40 CFR 49.156(e) and your permit application will
be granted or denied no later than 90 days after the receipt of your coverage request.
Your reviewing authority will send you a letter notifying you of the approval or denial of your Request for
Coverage under this General Permit if the reviewing authority determines that your Request for Coverage under
this General Permit has all the relevant information and is complete. Such a letter is a final permit action for
purposes of judicial review only for the issue of whether your source qualifies for this General Permit

Applicants are welcome to send comments on the U.S. Environmental Protection Agency’s (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. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

United States Environmental Protection Agency
General Permit for New or Modified Minor Sources of Air Pollution in
Indian Country
http://www.epa.gov/air/tribal/tribalnsr.html

Request for Coverage under the General Air Quality Permit for New or Modified
True Minor Source Boilers and Emergency Engines in Indian Country
Last Modified: July 1, 2016
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 C to the
General Air Quality Permit for New or Modified Minor Source Boilers and Emergency Engines or visit:
http://www.epa.gov/air/tribal/tribalnsr.html.
For assistance with this application please contact your reviewing authority.
For instructions on completing this application please see the document “Instructions for Requesting Coverage
under the General Air Quality Permit for New or Modified True Minor Source Boilers and Emergency Engines in
Indian Country.”

Section 1: Contact Information
1. Business Name:

2. Date:

3. Site Address:

4. County:

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

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

7. Owner:

8. Telephone Number of Owner:

9. Mailing Address of Owner:

10. Correspondence Address:
Company Name:
c/o:
Address:

11. Authorized Contact Person:
Name:
Title:
Phone:

Email:
FAX:

EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Section 2: Facility Information for Requesting Coverage under the General Air Quality Permit for
New or Modified Minor Source Boilers and Emergency Engines
12. This application is for (check all that apply):
A new boiler source and/or emergency engine (please describe the proposed new source).
_______________________________________________________________________________________________
_______________________________________________________________________________________________
A modification to an existing boiler and/or emergency engine source (please describe the modification below). The
definition of “modification” can be found at 40 CFR 49.152(d), and in the “Instructions” document.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
13. North American Industry Classification System (NAICS)/Standard Industrial Classification (SIC) Code and/or
description of the facility:
_______________________________________________________________________________________________
_______________________________________________________________________________________________



















11**** NAICS Agriculture, greenhouses
2211** NAICS Electric Power Generation
321*** NAICS Wood product manufacturing (except sawmills)
311*** NAICS Food manufacturing
327*** NAICS Nonmetallic mineral product manufacturing (except Ready-Mix Concrete)
424*** NAICS Wholesale trade, nondurable goods
611110 NAICS Elementary and Secondary Schools
611210 NAICS Junior Colleges
611310 NAICS Colleges, Universities, and Professional Schools
62**** NAICS Health care and social assistance
721120 NAICS Casino Hotels
813110 NAICS Religious organizations
92**** NAICS Public administration
2*** - 3*** SIC
Manufacturing
5***
SIC
Wholesale and Retail Trade
7011
SIC
Hotels and Motels
82**
SIC
Educational Services
Other – please specify _____NAICS; _____SIC

14. Will your new or modified boiler and/or emergency engine be located in an ozone nonattainment area?
Information on the ozone attainment status of the area where your boiler and/or emergency engine is/will
be located can be found at: http://www.epa.gov/airquality/greenbook/.
Yes

No

If yes, specify the classification of the ozone nonattainment area:
Marginal

Moderate

Request for Coverage: Boilers and Emergency Engines
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Serious

Severe

Extreme

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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

15. Will the PTE of your new boiler and/or emergency engine, or the emissions increase from your modified existing
boiler and/or emergency engine, 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 boiler and/or emergency engine may be
calculated using the PTE calculator available online at: http://www.epa.gov/air/tribal/tribalnsr.html. Be sure to
include all new or modified emission units at the facility.
Pollutant

Attainment Area

Nonattainment Area

Carbon Monoxide (CO)

10 tpy

5 tpy

Particulate Matter (PM)

10 tpy

5 tpy

Particulate Matter (PM10)

5 tpy

1 tpy

Particulate Matter (PM2.5)

3 tpy

0.6 tpy

Sulfur Dioxide (SO2)

10 tpy

5 tpy

Nitrogen Oxides (NOX)
Volatile Organic
Compounds (VOCs)

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 reviewing
authority to confirm that your boiler and/or emergency engine will not need a permit. If you answered
‘Yes,’ continue on to the next question.
16. If located in an attainment, unclassifiable, or attainment/unclassifiable area, will the PTE of your boiler
and/or emergency engine be less than 250 tpy for PM, PM10, PM2.5, VOCs, NOX, CO, and SO2, each
individually? Be sure to include all existing, new, and modified emission units at the facility.
Yes

No

If you answered ‘No,’ your source does not qualify for the General Permit. 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. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

17. If located in a nonattainment area for any pollutant, will the PTE of your boiler and/or emergency engine
for the particular nonattainment pollutant be less than the NSR major source thresholds specified in the
table below (based on nonattainment classification)? The emissions from your boiler and/or emergency
engine may be calculated using the PTE calculator provided at
http://www.epa.gov/air/tribal/tribalnsr.html. Be sure to include all existing, new, and modified emission
units at the facility.
Pollutant
Ozone

PM10
CO
SO2, NO2, PM2.5

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
Moderate
Serious
Moderate
Serious

10 tpy of VOC or NOX
100 tpy
70 tpy
100 tpy
50 tpy

No nonattainment classification

100 tpy

Yes

No

N/A - Not located in any nonattainment area

If you answered ‘No,’ your source does not qualify for the General Permit. Please contact reviewing authority
to apply for a site-specific permit. If you answered ‘Yes’ or ‘N/A,’ continue on to the next question.
18. Will the PTE of your boiler and/or emergency engine be below 10 tpy for a single HAP or 25 tpy for any
combination of HAPs? The emissions from your boiler and/or emergency engine may be calculated using
the PTE calculator provided at http://www.epa.gov/air/tribal/tribalnsr.html. Be sure to include all
existing, new, and modified emission units.
Yes

No

If you answered ‘No,’ your source does not qualify for the minor NSR program. 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. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Section 3: Technical Information for Requesting Coverage under the General Air Quality Permit
for New or Modified Minor Source Boilers and Emergency Engines
If needed, additional pages may be provided and added after this one. Use a unique ID# for each piece of
equipment.
Information regarding the emission units at your facility is required by 40 CFR 49.154 and 40.160. Please
provide the information below for all equipment at your facility. For each emissions unit, include supporting
documentation for the PTE of the unit with your Request for Coverage. In addition, for existing emissions units,
include the most recent actual annual emissions. See 40 CFR 49.154(a)(2). (For more information on how to
calculate actual emissions, you may go to: http://www.epa.gov/air/tribal/tribalnsrcalculators.html.) As needed,
please include other relevant information with your Request for Coverage (including any equipment not
identified below).
19. Boilers and Heaters
Unit
ID #

Unit Description
(include whether it is a new,
modified or existing boiler or
heater)

Fuel
Type(s)

Maximum
Rated Capacity
(MMBtu/hr)

Manufacturer

Date of
Construction
(mm/dd/yyyy)

20. Select Operational Limitation (choice will be reflected in the Approval of Request for Coverage, see Appendix A for
additional details about each option)
Option 1: Gaseous and/or Liquid Fuels for Boilers and Heaters and All Fuel Types for Engines – attainment,
unclassifiable, or attainment/unclassifiable areas and marginal and moderate ozone nonattainment areas – true minor
(Permit Condition 17)
Option 2: Gaseous Fuel for Boilers and Heaters and All Fuel Types for Engines – attainment, unclassifiable, or
attainment/unclassifiable areas and marginal and moderate ozone nonattainment areas – synthetic minor - (Permit
Condition 21.a)
Option 3: Gaseous and/or Liquid Fuels for Boilers and Heaters and All Fuel Types for Engines – serious ozone
nonattainment areas – true minor (Permit Condition 18)
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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Option 4: Gaseous Fuels for Boilers and Heaters and All Fuel Types for Engines – serious ozone nonattainment areas
– synthetic minor (Permit Condition 21.b)
Option 5: Gaseous Fuels for Boilers and Process Heaters and All Fuel Types for Engines – severe ozone
nonattainment areas – true minor (Permit Condition 19.a)
Option 6: Gaseous and/or Liquid Fuels for Boilers and Process Heaters and All Fuel Types for Engines – severe ozone
nonattainment areas – true minor (Permit Condition 19.b)
Option 7: Gaseous Fuels for Boilers and Process Heaters and All Fuel Types for Engines – severe ozone
nonattainment areas – synthetic minor (Permit Condition 21.c)
Option 8: Gaseous Fuels for Boilers and Process Heaters and All Fuel Types for Engines – extreme ozone
nonattainment areas – true minor (Permit Condition 20)
21. Emergency Engines
Unit
ID #

Unit Description
(include whether new, modified or
existing and purpose)

Fuel Type(s)

Maximum
Rated
Capacity
(horsepower
(hp))

Manufactured
Date
(mm/dd/yyyy)

Model
Year

22. Volatile Liquid Storage Tanks
This section applies to storage tanks used to store liquid materials. Please provide the following information for
each storage tank.
Unit
Type of
Capacity
Vapor pressure Is the tank above or Date of Installation
ID#
Liquid
(gallons)
of Liquid (psi)
underground?
(if existing)

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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Section 4: Information on Completing Screening Processes that have to be Satisfied to Request
Coverage under the General Air Quality Permit for New or Modified Minor Source Boilers and
Emergency Engines
23. Threatened or Endangered Species
Have you demonstrated that you meet one of the criteria listed in Appendix B with respect to 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? If you answered ‘No,’ you cannot request coverage
under this permit.
Yes

No

If you answered ‘Yes,’ then you need to provide the appropriate documentation to the EPA to qualify for
coverage under this permit. Please indicate under which criterion in Appendix B you are satisfying this
requirement:
A

B

C

D

E

24. Historic Properties
Have you completed the screening process in Appendix C to determine if the construction, modification or
operation of your new or modified minor source of air pollutants has the potential to cause effects to historic
properties (pursuant to the NHPA)? If you answered ‘No,’ you cannot request coverage under this permit.
Yes

No

If you answered ‘Yes,’ then provide the appropriate documentation to the EPA to qualify for coverage under
this permit.

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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Section 5: Additional Information about this General Air Quality Permit for New or Modified
Minor Source Boilers and Emergency Engines
This section provides information on the sizes of sources in terms of emissions that are eligible for the General Permit.
The emission limitations and standards in this permit are expected to ensure that source-wide emissions are below the
rates shown in the following table. The emissions rates for your source may be less depending on the option selected
under Item 20.

Pollutant of
Concern

Attainment,
Unclassifiable or
Attainment/
Unclassifiable Areas

CO

96.7 tpy

VOC

18.7 tpy

NOX

61.1 tpy

PM

14.7 tpy

96.7 tpy
18.7 tpy
(marginal and moderate ozone areas)
16.3 tpy
(serious ozone areas)
11.8 tpy
(severe ozone areas)
3.4 tpy
(extreme ozone areas)
61.1 tpy
(marginal and moderate ozone areas)
48.2 tpy
(serious ozone areas)
24.6 tpy
(severe ozone areas)
9.4 tpy
(extreme ozone areas)
NA

PM10

24.0 tpy

24.0 tpy

PM2.5

18.6 tpy

18.6 tpy

Nonattainment Areas

You should contact your reviewing authority if you intend to rely on the emission limitations and standards in this
General Permit to prevent having to obtain a Title V permit.

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EPA Form No. 5900-369
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: _____________________________Name: ____________________________Date:__________
(Signature)

(Print or Type)

Title: _____________________________________

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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

Appendix A – Summary of Eligibility Criteria – Operational Limits
“All boilers rated ≥ 10.0 MMBtu/hr” – means you should create a list of the heat input capacity of all of your boilers that
are individually rated 10 MMBtu/hr and greater (e.g., 10 MMBtu/hr, 11 MMBtu/hr, 23 MMBtu/hr, and 56 MMBtu/hr).
Your “Maximum Combined Capacity” is the sum of that list (e.g., 10+11+23+56 = 100 MMBtu/hr). To be eligible the sum
must not exceed the value listed in the table.
“All small boilers and process heaters rated < 10.0 MMBtu/hr” – means you should create a list of the heat input capacity
of all of your boilers and process heaters that are individually rated less than 10 MMBtu/hr (e.g., 5 MMBtu/hr, 1
MMBtu/hr, 0.5 MMBtu/hr, and 0.09 MMBtu/hr). Your “Maximum Combined Capacity” is the sum of that list (e.g.,
5+1+0.5+0.09 = 6.59 MMBtu/hr). To be eligible the sum must not exceed the value listed in the table.
Ozone Attainment, Unclassifiable and Attainment/Unclassifiable Areas and Marginal and Moderate
Ozone Nonattainment Areas (choose Number 1 or 2)
1. The combined maximum rated capacity of all boilers, process heaters, and engines at the permitted source shall not
exceed the following parameters, as applicable. Boilers and process heaters may use gaseous and/or liquid fuels.
Engines may burn any fuel type.
Permitted Source Using Gaseous and/or Liquid Fuels in Boilers and Process Heaters
and All Fuel Types in Engines
Maximum Combined
Type of Emission Units
Capacity
All boilers rated ≥ 10.0 MMBtu/hr
200 MMBtu/hr
All small boilers and process heaters rated < 10.0 MMBtu/hr
30 MMBtu/hr
All emergency generators (any fuel)
1,500 hp
2. Synthetic Minor Limits:
i. Annual fuel use of gaseous fuel in all boilers and process heaters shall not exceed 1,500 million standard
cubic feet (MMscf) per year in any 12-month period; and
ii. Combined maximum rated capacity of all emergency engines (all fuel types) shall not exceed 1,500 hp.
Serious Ozone Nonattainment Areas (choose Number 3 or 4)
3. The combined maximum rated capacity of all boilers, process heaters, and engines at the permitted source shall
not exceed the following parameters, as applicable. Boilers and process heaters may use gaseous and/or liquid
fuels. Engines may burn any fuel type.
Permitted Source Using Gaseous and/or Liquid Fuels in Boilers and Process
Heaters and All Fuel Types in Engines
Type of Emission Units
Maximum Combined Capacity
All boilers rated ≥ 10.0 MMBtu/hr
160 MMBtu/hr
All small boilers and auxiliary heaters rated < 10.0
20 MMBtu/hr
MMBtu/hr
All emergency generators (all fuels)
1,500 hp
4. Synthetic Minor Limits:
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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

i. Annual fuel use of gaseous fuel in all boilers and process heaters shall not exceed 720 MMscf/yr in any 12month period; and
ii. Combined maximum rated capacity of all emergency engines (all fuel types) shall not exceed 1,500 hp.
Severe Ozone Nonattainment Areas (choose Number 5, 6, or 7)
5. Each permitted source using only gaseous fuel in boilers and process heaters shall meet the following combined
maximum allowable rating of emission units. Boilers and process heaters may also use diesel or biodiesel as an
emergency backup fuel for up to 500 hours per calendar year. Engines may burn any fuel type.
Permitted Source Using Only Gaseous Fuel in Boilers and Heaters and All Fuel Types
in Engines
Type of Emission Units
Maximum Combined Capacity
All boilers rated ≥ 10.0 MMBtu/hr
160 MMBtu/hr
All small boilers and process heaters rated < 10.0
20 MMBtu/hr
MMBtu/hr
All emergency generators (any fuel)
1,000 horsepower (hp)
6. Each permitted source with boilers and heaters that use gaseous and/or liquid fuels shall meet the following
combined maximum allowable rating of emission units. Engines may burn any fuel type.
Permitted Source Using Gaseous and/or Liquid Fuels in Boilers
and Heaters and All Fuel Types in Engines
Maximum Combined
Type of Emission Units
Capacity
All boilers rated ≥ 10.0 MMBtu/hr
120 MMBtu/hr
All small boilers and auxiliary heaters rated <
20 MMBtu/hr
10.0 MMBtu/hr
All emergency generators (all fuels)
1,000 hp
7. Synthetic Minor Limits
i. Annual fuel use of gaseous fuel in all boilers and process heaters shall not exceed 345 MMscf/yr in any 12month period; and
ii. Combined maximum rated capacity of all emergency engines (all fuel types) shall not exceed 1,000 hp.

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Extreme Ozone Nonattainment Areas
8. The combined maximum rated capacity of all boilers and process heaters at the permitted source shall not
exceed the following parameters, as applicable. The permitted source shall only use gaseous fuels in its boilers
and process heaters. Engines may burn any fuel type.
Permitted Source Using Gaseous Fuels in Boilers and Heaters
and All Fuel Types in Engines
Combined Allowed Maximum
Types of Emission Units
Rating of Emissions Units
All boilers rated ≥ 2.0 MMBtu/hr
25 MMBtu/hr
All small boilers and auxiliary
10 MMBtu/hr
heaters rated < 2.0 MMBtu/hr
All emergency generators (all fuels)
500 hp

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Appendix B – Threatened or Endangered Species Requirements
The purpose of this appendix is to assist you in completing the screening procedure for addressing threatened or
endangered species prior to submitting your Request for Coverage under the General Air Quality Permit for New or
Modified Minor Source Boilers and Emergency Engines in Indian Country. In order to be eligible for coverage under the
General Permit, you must demonstrate that you qualify under one of the criteria listed in this appendix with respect to
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.
This appendix provides you information on the following:
•
•

Section 1.0: Listed Species Eligibility Criteria and
Section 2.0: Guidance for Determining Which Listed Species Criterion Applies.

1.0

Listed Species Eligibility Criteria

To be eligible for coverage under the General Permit, you must obtain confirmation from the EPA that you completed
the screening procedure and meet one of the eligibility criteria listed below. You must also specify in your submittal the
basis for your selection of the applicable eligibility criterion and provide documentation supporting the criterion
selected. If you have not obtained confirmation from the EPA regarding listed species eligibility criteria, you will not be
eligible for coverage under the General Permit, and you must apply for a site-specific permit.
Note: (1) Your determination must provide sufficient documentation to support your determination that you satisfy the
requirements of the particular criterion you have selected. (2) While coordination between you and the U.S. Fish and Wildlife
Service (FWS) and/or the National Marine Fisheries Service (NMFS; together, the “Services”) is not necessarily required in all cases,
the EPA encourages you to coordinate with the relevant Service(s) and to do so early in the planning process prior to submitting
your Request for Coverage.

You must comply with any applicable terms, conditions, or other requirements developed in the process of meeting
any of the eligibility criteria (A-E) in this section to remain eligible for coverage under the General Permit.
Documentation of these requirements shall be maintained by the permittee for the duration of time the affected
emissions unit(s) is (are) covered under the General Permit.
The following is a summary of the five eligibility criteria. See Section 2.0 for detailed instructions to determine which
criterion applies for your specific action:
Criterion A:
No federally-listed threatened or endangered species or designated critical habitat(s) of such species are likely to occur
within the action area for your project.1
Criterion B:
Federally-listed threatened or endangered species or their designated critical habitat(s) are likely to occur within the action
area of your source, but the construction and operation of your new minor source or construction and operation of the
1

Action area means all areas to be affected directly or indirectly by your project and may be broader than the immediate project
area [See, e.g., 50 CFR 402.02].
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modification to your existing minor source is not likely to adversely affect listed threatened or endangered species or
critical habitat. This determination may include consideration of any air pollution controls or other changes to the
construction and/or operation of your new or modified source that you will adopt to ensure that construction, modification
and operation of your new or modified source are not likely to adversely affect listed species or critical habitat. To
make this certification, you must include the following in your Request for Coverage documentation: (1) identify any
federally listed species and/or designated critical habitat located within the action area of your source; (2) the distance
between your site and the listed species or designated critical habitat (in miles); and (3) any other information
necessary (e.g., a detailed map of the action area and supporting justification) to show that the
construction/modification and operation of your new or modified source are not likely to cause any adverse effects to the
listed threatened or endangered species or their critical habitat.
Criterion C:
Coordination between you and the Service(s) has been concluded and has addressed the effects of your new or
modified minor source’s construction/modification and operation on federally-listed threatened or endangered species
and federally-designated critical habitat. The coordination must result in a written concurrence from the relevant
Service(s) that your new or modified minor source’s construction/modification and operation are not likely to adversely
affect listed species or critical habitat. You must include copies of the correspondence between yourself and the
Service(s) with your submittal.
Criterion D:
Consultation between another Federal Agency and the Service(s) under section 7 of the ESA has been concluded. The
consultation must have addressed the effects of your minor source’s construction/modification and operation on
federally-listed threatened or endangered species and federally-designated critical habitat. The result of this
consultation must be either:
1. A biological opinion that concludes that the action in question (taking into account the effects of your
source’s construction/modification and operation) is not likely to jeopardize the continued existence of
listed species, or result in the destruction or adverse modification of critical habitat; or
2. Written concurrence from the applicable Service(s) with a finding that the source’s
construction/modification and operation are not likely to adversely affect federally-listed species or
federally-designated critical habitat.
You must include copies of the relevant documentation cited above in your submittal.
Criterion E:
You have obtained an incidental take permit from the Service(s) under section 10 of the ESA in connection with your
construction/modification and operation activities, and this permit addresses the effects of the source on relevant
federally-listed species and federally-designated critical habitat. You must include copies of the incidental take permit
and associated documentation and correspondence between yourself and the Service(s) with your submittal.

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2.0

Determining Which Criterion Applies

To qualify for the General Permit, you need to meet one of the five criteria listed above. You must follow the
procedures in Steps 1 through 5 below to determine the listed species criterion, if any, under which your project is
eligible for permit coverage.
Step 1 - Determine if Previous or Separate Assessments Have Already Addressed Your Source.
You should first determine whether you are eligible to select either Criterion D or E based on an ESA section 7
consultation previously completed by another Federal Agency (Criterion D) or an ESA section 10 permit (Criterion E)
issued by the Service(s) as follows:
Meeting Criterion D: If consultation under section 7 of the ESA has been concluded in connection with another Federal
Agency’s involvement with your source, you may be eligible to select Criterion D. To be eligible to select Criterion D, you
must confirm that all the following are true:




A consultation between a Federal Agency and the Service(s) under section 7 of the ESA has been concluded.
Consultations can be either formal or informal, and would have occurred in connection with a separate action by
a separate Federal Agency (e.g., as part of a separate Federal Agency’s authorization for you to construct or
operate your business in Indian country). The consultation must have addressed the effects of the construction,
modification and operation of your new or modified source on all federally-listed threatened or endangered
species and all federally-designated critical habitat in your action area. The result of this consultation must be
either:
a. A biological opinion that concludes that the construction, modification and operation of your new or
modified source is not likely to jeopardize the continued existence of any listed species, nor result in the
destruction or adverse modification of any designated critical habitat. The consultation must have included
consideration of the effects of your facility’s emissions and other related activities on all listed species and
designated critical habitat in your action area; or
b. Written concurrence (e.g., letter of concurrence) from the applicable Service(s) with a finding that the
construction, modification and operation of your new or modified source are not likely to adversely affect
listed species or designated critical habitat. The consultation must have included the effects of your
facility’s emissions and other related activities on all the listed species and designated critical habitat in
your action area.
The consultation remains current, in accordance with 50 CFR §402.16; or, if re-initiation of consultation is
required (e.g., due to a new species listing or critical habitat designation or new information), such reinitiated
consultation is concluded, and the result of the consultation is consistent with the statements above. Attach a
copy of any consultation re-initiation documentation from the Service(s) or other consulting Federal Agency.

If all of the above are true, you may select Criterion D. You must also provide a description of the basis for the
criterion selected. In your submittal you must also provide the Biological Opinion (or Public Consultation Tracking
System tracking number) or concurrence letter and any other documentation supporting your determination.
If any of the above is not true, you may not select Criterion D. For example: if the biological opinion or written
concurrence from the Service(s) did not include the effects of your source’s air emissions or other-related activities as
described above; or if the previous consultation covered some but not all of the listed species or critical habitat in your
action area; or if the consultation is no longer current (e.g., due to new species listings); then you are not eligible under
Criterion D.

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Meeting Criterion E: You have obtained an incidental take permit under section 10 of the ESA, and this permit
addresses the effects of the construction/modification and operation of your new or modified source on federallylisted species and designated critical habitat in your action area.
You may rely on a section 10 permit that you have previously obtained so long as it addresses the
construction/modification and operation of your new or modified source and all federally-listed species and
designated critical habitat in your action area. (Note: If you do not hold a section 10 permit already, you can
consider obtaining one, however, it may be more efficient to instead meet the requirements for Criterion A, B or C
as described in Steps 2 – 5.)
If you choose to apply for a new section 10 permit, you must follow applicable Service procedures (see 50 CFR
§17.22(b)(1) for FWS and §222.22 for NMFS). Application instructions for section 10 permits for FWS and NMFS can be
obtained by accessing the FWS and NMFS websites (http://www.fws.gov and http://www.nmfs.noaa.gov) or by
contacting the appropriate FWS and NMFS regional office.
If the above is true, you may select Criterion E. You must also provide a description of the basis for the criterion
selected. In your submittal you must provide a copy of the permit issued by the Service(s).
If the above is not true, you may not select Criterion E at this time and must proceed to Step 2. For example, if a
permit has been issued under section 10 of the ESA, but the permit did not consider the effects of the facility’s air
emissions and/or emission-related activities on all federally listed species and designated critical habitat on your
species list, you are not eligible under Criterion E.
Step 2 - Determine if Listed Threatened or Endangered Species or their Designated Critical Habitat(s) are Likely to
Occur within the Action Area of your Minor Source.
You must determine, to the best of your knowledge, whether species federally listed as either threatened or
endangered, or their designated critical habitat(s), are located within the action area of your minor source.2 This is a twostep process. The first step is to determine your action area. When defining the boundaries of your action area, you should
take into account the following criteria:







Ground disturbance – Effects during construction, maintenance and operation of the facility should be
considered.
Changes in water quality/quantity (both surface and groundwater) – This would include effects that may extend
far beyond the footprint of the facility. An example may be stormwater runoff from impervious surfaces
(containing sediments or other contaminants) on the site that may reach water bodies (including ditches that
empty into water bodies) some distance from a facility. All receiving water bodies that could receive pollutants
from the facility’s construction, maintenance, or operation should be included in the action area.
Air Quality Impacts – Effects during construction, maintenance and operation of the facility should be
considered.
Lighting effects – Effects during construction, maintenance and operation of the facility should be considered.
Noise Disturbance – Effects during construction, maintenance and operation of the facility should be considered.

2

For definitions of terms that you might encounter when addressing the listed species requirements, go to:
http://www.fws.gov/midwest/endangered/glossary/index.html and http://www.fws.gov/northeast/nyfo/es/actionarea.htm.

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Note: If you have questions about determining the extent of the action area, you should coordinate with the
local Service field office as noted below. If site-specific conditions exist such that the action area would be
limited to the facility footprint, but that fact may not be obvious from a map or figure, submit a narrative
description of the action area in addition to a map for evaluation of the action area selected. To determine
the field office that corresponds to your project site, visit:
http://www.fws.gov/endangered/regions/index.html and http://www.nmfs.noaa.gov/ (under the left tab for
“Regions”).
After determining the boundaries of the action area, you will next determine if listed species and/or critical habitat are
expected to exist there. Relevant sources of information regarding the locations of listed species and critical habitats are
often organized along county and/or township lines. You should thus first identify the counties and/or townships within
which your action area is located. You would then consult relevant sources of information regarding the locations of listed
species and critical habitats. The local offices of the FWS and NMFS often maintain lists of federally listed threatened or
endangered species on their Internet sites. For FWS terrestrial and aquatic species information, you can use the FWS online mapping tool, the Information, Planning, and Consultation System, located at http://www.fws.gov/ipac/.
In most cases, listed species and designated critical habitat lists will allow you to determine if any such species or
habitat exists in your county or township. You can also find critical habitat designations and associated
requirements at 50 CFR Parts 17 and 226 (see http://www.access.gpo.gov). You may also use the FWS Critical
Habitat Portal (see http://criticalhabitat.fws.gov/crithab/).


If there are no listed species and/or critical habitat in the counties/townships where your action area is
located you may select Criterion A. You must also provide a description of the basis for the criterion selected
and provide documentation supporting the criterion selected in your submittal.



If there are listed species and/or critical habitat in the counties/townships in your action area, you should
contact your local FWS or NMFS office to determine if the listed species are known to exist within the
specific action area of your minor source and if any designated critical habitat areas overlap the action area of
your minor source.
o If your local FWS or NMFS office indicates that these species and/or critical habitat could exist within the
action area of your minor source, you must do one of the following to determine if the species and/or
critical habitat may actually be present in or may use your action area:
 Conduct visual inspections. This method may be particularly suitable for sites that are smaller in
size or located in non-natural settings such as highly urbanized areas or industrial parks where
there is little or no natural habitat.
 Conduct a formal biological survey. In some cases, particularly for larger sites, biological surveys
may be an appropriate way to assess whether species are located within the action area of your
minor source. Biological surveys are frequently performed by environmental consulting firms. A
biological survey may in some cases be useful to conduct in conjunction with Steps 3, 4 or 5 of
these instructions.



If, after performing one or more of the assessments above, you determine that there are no listed species
or critical habitat in your action area, you may select Criterion A. You must also provide a description of the
basis for the criterion selected and provide documentation supporting the criterion selected in your submittal.



If, listed species or critical habitat are located in your action area then proceed to step 3.

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Step 3 - Determine if the Construction/Modification or Operation of Your New or Modified Minor Source is Likely
to Adversely Affect Listed Threatened or Endangered Species or Designated Critical Habitat.
If in Step 2 you determine, based on communication with your local FWS or NMFS office, or otherwise, that listed
species and/or critical habitat could exist within the action area of your new or modified minor source, you must
next assess whether the construction/modification or operation of your new or modified minor source is likely to adversely
affect listed threatened or endangered species or designated critical habitat.
Potential adverse effects from construction/ modification and operation activities include direct and indirect effects and
could include, but are not limited to, the following:





Habitat Disturbance. Surface disturbance activities such as excavation, site development, grading, and associated
light and noise may adversely affect listed species or their habitat.
Operation of the Source. Source operations could result in additional traffic, noise and light that could affect
species or habitat.
Water-Related Impacts. Changes in water usage or water discharges may affect listed species or their habitat.
Air Emission Impacts. Increases in emission of certain pollutants may in certain cases affect vegetation growth
patterns that can affect listed species or their habitat.

The scope of effects to consider will vary with each site and project. If you are having difficulty determining whether
your project is likely to adversely affect listed species or critical habitat, or one of the Services has already raised
concerns to you, you should contact the appropriate office of the FWS or NMFS for assistance.


If adverse effects to listed threatened or endangered species or their critical habitat are not likely, then you
may select Criterion B. You must provide the following specific information with your submittal:
1 . The federally listed species and/or designated habitat that are located within the action area of your minor
source;
2 . The distance between your site and the listed species or designated critical habitat (in miles); and
3 . Any other information necessary to show that the construction/modification and operation of your source are
not likely to cause any adverse effects to the listed threatened or endangered species or their critical habitat.



If adverse effects to listed threatened or endangered species or their critical habitat are likely, you must
follow Step 4 below.

Step 4 - Determine if Measures Can Be Implemented to Avoid Adverse Effects.
If you determine in Step 3 that adverse effects from the construction/modification or operation of your new or
modified minor source are likely to occur, you can still select eligibility Criterion B if you undertake appropriate
measures to avoid or eliminate the likelihood of adverse effects prior to seeking coverage under the General Permit.
These measures may involve relatively simple changes to construction activities such as re-routing construction to
bypass an area where species are located, relocating source activities, or modifying the “footprint” of the site.


If you are able to implement appropriate measures to avoid the likelihood of adverse effects, then you may
select Criterion B. The measures you adopt to avoid or eliminate adverse effects must be implemented for the
duration of the construction/modification and operation of your new or modified minor source and your
coverage under this General Permit. You must also provide a description of the basis for the criterion selected,

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and the following specific information on your Request for Coverage Form: (1) the federally listed species
and/or designated habitat that are located within the action area of your minor source; (2) the distance between
your source and the listed species or designated critical habitat (in miles); and (3) what steps were or will be
taken to avoid the likelihood of adverse effects.


If you cannot determine sufficient measures to implement to avoid the likelihood of adverse effects, you
must follow the procedures in Step 5.

Step 5 - Coordinate with the Service(s).
If in Step 4 you cannot determine sufficient measures to avoid the likelihood of adverse effects, you must contact the
applicable Service(s). You may still be eligible for coverage under the General Permit if the likely adverse effects can be
addressed through meeting criterion C.


Criterion C: You have coordinated with the Service(s) and have addressed the effects of the
construction/modification and operation of your new or modified minor source on federally-listed threatened
or endangered species and federally-designated critical habitat. The Service(s) must provide written
concurrence that the construction/modification and operation of your new or modified minor source is not
likely to adversely affect listed species or critical habitat.
o

If you have obtained the Service(s) written concurrence as described above, then you may select Criterion C.
As part of your submittal, you must provide a description of the basis for the criterion selected and must
include copies of the correspondence between you and the applicable Service(s).

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Appendix C – Historic Property Screening Process
1.0 Background
The purpose of this appendix is to assist you in completing the
screening procedure for addressing historic properties that are
either listed on, or eligible for listing on, the National Register for
Historic Places prior to submitting your Request for Coverage under
the General Air Quality Permit for New or Modified Minor Source
Boilers and Emergency Engines in Indian Country. In order to be
eligible for coverage under the General Permit, you must
demonstrate that you qualify under one of the criteria listed in this
appendix with respect to the protection of historic properties under
the NHPA.

Key Terms
Historic property- prehistoric or historic districts,
sites, buildings, structures, or objects that are
included in or eligible for inclusion in the National
Register of Historic Places, including artifacts,
records, and remains that are related to and located
within such properties

SHPO – The State Historic Preservation Officer for
a particular state

To address any issues relating to historic properties, the EPA has
THPO or Tribal representative – The Tribal Historic
developed the screening process in this appendix to enable source
Preservation Officer for a particular Tribe or, if there is
owners/operators to: (1) appropriately consider the potential
no THPO, the representative designated by such Tribe
impacts, if any, resulting from the construction, modification, and/or
for NHPA purposes
operation of a new or modified emission source on historic
properties and, (2) if applicable, determine whether actions can be taken to mitigate any such impacts. Although each
decision that a specific minor source meets the requirements for coverage under this General Permit does not constitute a
separate Federal undertaking, the screening process in this appendix provides an appropriate site-specific means of
addressing historic property issues in connection with coverage under the General Permit.
If the impacts from your source have already been reviewed under another Federal agency’s approval process (e.g., the
Bureau of Indian Affairs authorizing operation of your source in Indian country) then documentation from that review
may satisfy the requirements of this section. In some cases the review by another agency will have evaluated the
impacts from site disturbance activities (e.g., site clearing), but not from air emissions. In such cases supplemental
evaluation may be required to complete the analysis.

2.0 Instructions for Source Owners/Operators
You are required to follow the screening process in this appendix to determine if the construction, modification or
operation of a new or modified minor source of air pollutants on your site has the potential to cause effects to historic
properties, and whether or not you need to contact your State Historic Preservation Officer (SHPO), Tribal Historic
Preservation Officer (THPO), or other tribal representative for further information. You may not submit your Request
for Coverage under the General Permit until you have completed this screening process and obtained confirmation of
satisfactory completion from the EPA. The following four steps describe how applicants can meet the historic
property requirements under this permit.

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Step 1 - Have prior professional cultural resource surveys or other evaluations determined whether
historic properties exist in the area of your proposed source? Or, have prior earth disturbances precluded
the existence of historic properties in the area of your proposed source?
If it has already been determined that no historic properties exist in the area of your proposed source based
on available information, including information that may be provided by your applicable SHPO, THPO, or
other tribal representative, then you may submit the appropriate documentation of “no historic properties
affected” with your submittal, and no further screening steps are necessary.
Similarly, if earth disturbances that have occurred prior to your project have eliminated the possibility that historic
properties exist on your site or in the area affected by your new or modified minor source, then you may submit the
appropriate documentation of “no historic properties affected” with your submittal, and no further screening steps are
necessary.
During the 30-day period following receipt of your screening process documentation by the EPA, the SHPO, THPO, or
other tribal representative may request that the EPA deny coverage under the General Permit based on concerns about
potential adverse impacts to historic properties. The EPA will evaluate any such request and notify you if any additional
information is needed to address adverse impacts to historic properties.
Step 2 - If you are constructing, or modifying a minor source of air pollutants, as defined in 40 CFR §49.152, you
must determine if the construction, modification or operation of the minor source will have an effect on
historic properties.
If your answer to the questions in Step 1 is “no,” then you must assess whether the activities related to the
construction, modification or operation of your new or modified minor source will have an effect on historic properties.
Activities that could have an adverse effect on historic properties could include, for example:







Excavations;
Demolitions of existing buildings;
Construction of foundations (e.g., for buildings, tanks or stacks);
Installations of underground tanks;
Addition of impervious surfaces; and
Increases in truck traffic during excavation, demolition, or construction.

Note: This list is not intended to be exhaustive. Other activities that are not on this list may involve earth-disturbing
activities and must also be examined for their potential to affect historic properties. For more information, go to the
National Park Service, National Register of Historic Places database found at
http://www.nps.gov/history/nr/research/index.htm.
The assessment may be based on a site map of your source and an analysis of historical sources, knowledge of the area,
an assessment of the types of activities you are engaging in, considerations of any controls and/or management
practices you will adopt to ensure that your activities will not have an effect on historic properties, and any other
relevant factors.
If you determine based on this assessment that the activities related to the construction, modification or operation of
your new or modified minor source will not cause effects to historic properties, then you may submit the appropriate
documentation of “no historic properties affected” with your submittal, and no further screening steps are necessary.
During the 30-day period following receipt of your screening process documentation by the EPA, the SHPO, THPO, or
other tribal representative may request that the EPA delay your coverage under the General Permit based on concerns
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about potential adverse impacts to historic properties. The EPA will evaluate any such request and notify you if any
additional information is needed to address adverse impacts to historic properties.
If you are installing or modifying equipment that has the potential to have an adverse effect on historic properties, then
you must proceed to Step 3.
Step 3 - If you are constructing or modifying a minor source and you have not satisfied the conditions in Steps
1-2, you must contact and consult with the appropriate historic preservation authorities.
Where you are constructing or modifying a minor source and you cannot determine in Step 2 that this activity will not
have effects on historic properties, then you must contact the relevant SHPO, THPO, or other tribal representative to
request their views as to the likelihood that historic properties may be adversely affected by the construction,
modification or operation of your new or modified minor source.
Note: Addresses for SHPOs and THPOs may be found on the Advisory Council on Historic Preservation’s (ACHP’s) website
(http://www.achp.gov/programs.html). In instances where a tribe does not have a THPO, you should contact the
appropriate Tribal government office designated by the tribe for this purpose when responding to this permit eligibility
condition.
You must submit the following minimum information in order to properly initiate your request for information:
1.
2.
3.
4.

Project name (i.e., the name or title most commonly associated with your project);
A narrative description of the project;
Name, address, phone and fax number, and email address (if available) of the operator;
Most recent U.S. Geological Survey map section (7.5 minute quadrangle) showing actual project location and
boundaries clearly indicated; and
5. Sections of site map that show locations where activities might cause an adverse effect on historic properties.
Without submitting this minimum information, your request cannot be considered. You will need to provide the
SHPO, THPO, or other tribal representative a minimum of 15 calendar days after they receive these materials to
respond to your request for information about your project. You are advised to get a receipt from the post office or
other carrier confirming the date on which your letter was received.
If you do not receive a response within 15 calendar days after receipt by the SHPO, THPO, or other tribal representative
of your request, then you may indicate this in your submittal, and no further screening steps are necessary. Or, if the
applicable SHPO, THPO, or other tribal representative responds to your request with an indication that no historic
properties will be adversely affected by the construction or modification of your minor source, then you may submit the
appropriate documentation of “no adverse effects” with your submittal, and no further screening steps are necessary.
If within 15 calendar days of receipt of your request the applicable SHPO, THPO, or other tribal representative
responds with a request for additional information or for further consultation regarding appropriate measures for
treatment or mitigation of effects on historic properties caused by the construction, modification or operation of your
minor source, you must comply with this request and proceed to Step 4.
During the 30-day period following receipt of your screening process documentation by the EPA, the SHPO, THPO, or
other tribal representative may request that the EPA place a hold on authorization based on concerns about potential
adverse impacts to historic properties. The EPA will evaluate any such request and notify you if any additional

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EPA Form No. 5900-369
EPA ICR No. 1230.27
OMB Control No. 2060-0003
Approval expires 4/30/2017

information is needed to address adverse impacts to historic properties before continuing review of your Request for
Coverage under the general permit.
Step 4 - Consultation with your applicable SHPO, THPO, or other tribal representative.
If, following your discussions with the appropriate historic preservation authorities in Step 3, the applicable SHPO, THPO,
or other tribal representative requests additional information or further consultation, you must respond with such
information or consult to determine impacts and appropriate measures to mitigate such impacts to historic properties
that may be caused by the construction, modification or operation of your new or modified minor source site. If after
consultation it is determined that there will be no adverse effects to historic properties, then you may submit the
appropriate documentation of “no adverse effects” with your submittal, and no further screening steps are necessary. If as
a result of your discussions with the applicable SHPO, THPO, or tribal representative, you enter into, and comply with, a
written agreement regarding treatment and/or mitigation of impacts on your site, then you may submit the appropriate
documentation of “adverse effects” with your submittal.
If, however, agreement on an appropriate treatment or mitigation plan cannot be reached between you and the SHPO,
THPO, or other tribal representative within 30 days of your response to the SHPO, THPO, or other tribal
representative’s request for additional information or further consultation, you may submit your screening process
documentation, but you must indicate that you have not negotiated measures to avoid or mitigate such effects. You
must also include the following with your submittal:
1. Copies of any written correspondence between you and the SHPO, THPO, or other tribal representative; and
2. A description of any significant remaining disagreements as to mitigation measures between you and the SHPO,
THPO, or other tribal representative.
During the 30-day period following receipt of your submittal by the EPA, the SHPO, THPO, ACHP or other tribal
representative may request that the EPA place a hold on confirmation based upon concerns regarding potential adverse
effects to historic properties. The EPA, in coordination with the SHPO, THPO, ACHP or other tribal representative, will
evaluate any such request and notify you if any additional measures to address potential adverse effects to historic
properties are necessary.

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