Form 7630-5 REPORT OF CHANGE OF OWNERSHIP

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

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
REGION 10 FEDERAL AIR RULES FOR INDIAN RESERVATIONS

REPORT OF CHANGE OF OWNERSHIP
Applicability: Air pollution sources regulated by 40 Code of Federal Regulations Part 49.138.
Report change of ownership within 90 days after the effective date of change.

INSTRUCTIONS: Complete applicable parts of Sections A, B, C and D.
A. GENERAL INFORMATION
Identifying Information
Previous Source (Facility) Name_________________________________________________
Previous Owner’s Name ________________________________________________________
New Source (Facility) Name _____________________________________________________
Air Quality Operating Permit No. (if applicable) _____________________________________
Nature of the Business_________________________________________________________
Telephone (_____) _______-________

Facsimile (_____)______-________

Source Physical Address: Street ________________________________________
City______________________ County_______________ State ________ ZIP _________-________
Indian Reservation Name______________________________________________
Compliance Contact Person ______________________________ Title__________________________
(Local Person responsible for source compliance with this rule)

Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________
Contact Person Mailing Address: Street (or PO Box #) __________________________________
City______________________ County______________ State ________ ZIP _________-________

e.mail address _____________________________

EPA Form 7630-5

Page 1 of 6

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

A. GENERAL INFORMATION Cont.
Owner’s Name___________________________________________________
New Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________
Owner Mailing Address: Street ( or PO Box #) _______________________________
City______________________ County_________________ State ________ ZIP _________-________
e.mail address ______________________________
Contact ____________________Title__________________________
(Person authorized to receive requests for data and information)

Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________
Contact Person Mailing Address: Street (or PO Box #) ________________________________________
City______________________ County___________________ State ________ ZIP _________-________
e.mail address _______________________________

Operator’s Name____________________________________________(If different from owner)
New Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________
Operator Mailing Address: Street ( or PO Box #) _______________________________
City______________________ County_________________ State ________ ZIP _________-________
e.mail address ______________________________
Contact ____________________Title__________________________
(Person authorized to receive requests for data and information)

Telephone (_____) _______-________ Ext. _________ Facsimile (_____)______-________
Contact Person Mailing Address: Street (or PO Box #) ________________________________________
City______________________ County___________________ State ________ ZIP _________-________
e.mail address _______________________________

Effective Date of Change of Ownership
Date.____/____/________

EPA Form 7630-5

Page 2 of 6

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

B. ATTACHMENTS
Include any of the following information as attachments to this form that requires updating as a result of the
change of ownership
† Process flow chart identifying all processing, combustion, handling, storage, and emission control equipment
† Narrative description of the production processes and air pollution control equipment
† List of all emission units and air pollution generating activities; include model and serial numbers for portable
equipment
† Plot Plan
9
9
9
9

Location of all emission units and air pollution generating activities
Property lines for the air pollution source
Elevation above grade for each emission release point
Distance and direction to nearest residential or commercial property

† Type and quantity of fuels, including sulfur content of fuels, used on a daily, annual and maximum hourly basis
† Type and quantity of raw materials used or final product produced on a daily, annual and maximum hourly basis
† Typical operating schedule, including number of hours per day, number of days per week and number of weeks
per year
† List of estimated efficiency of air pollution control equipment under present or anticipated operating conditions
† Estimates of the total actual emissions from the air pollution source for the following air pollutants: particulate
matter, PM10, PM2.5, sulfur oxides (SOx), nitrogen oxides (NOx), carbon monoxide (CO), volatile organic
compound (VOC), lead (Pb) and lead compounds, ammonia (NH3), fluorides (gaseous and particulate), sulfuric
acid mist (H2SO4), hydrogen sulfide (H2S), total reduced sulfur (TRS) and reduced sulfur compounds, including
all calculations for the estimates
† Other (provide details)
Confidential Treatment of Information
You may assert a business confidentiality claim covering any portion of the submitted information as provided in
40 C.F.R. part 2, subpart B. Please submit any information you claim as confidential business information
separately, along with your claim of confidentiality. Note that emissions data and information necessary to
determine emissions is not entitled to confidential treatment. Failure to assert a claim in the manner described in
40 C.F.R. part 2, subpart B allows the submitted information to be released to the public without further notice.
Information subject to a business confidentiality claim may be disclosed by EPA only to the extent set forth in
the above-cited regulations

EPA Form 7630-5

Page 3 of 6

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

C. TABLE OF ANNUAL EMISSIONS
The following table should be completed by inserting estimates of the total actual emissions in tons/year
for all pollutants contained in your worksheet stated above.

Pollutant

Total
Emissions

PM
PM10
PM 2.5
SOx
NOx
CO
VOC
Pb
NH3
Fluorides
H2SO4
H2S
TRS
RSC
Definition of acronyms
PM
PM10
PM2.5
SOx
NOx
CO
VOC
Pb
NH3
Fluorides
H2SO4
H2S
TRS
RSC

EPA Form 7630-5

Particulate Matter
Particulate Matter less than 10 microns in size
Particulate Matter less than 2.5 microns in size
Sulfur Oxides
Nitrogen Oxides
Carbon Monoxide
Volatile Organic Compound
Lead and lead compounds
Ammonia
Gaseous and particulates
Sulfuric Acid Mist
Hydrogen Sulfide
Total Reduced Sulfur
Reduced Sulfur Compounds

Page 4 of 6

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

D. OWNER OR OPERATOR’S CERTIFICATION OF TRUTH, ACCURACY AND COMPLETENESS
Certifying Official Information: Identify the certifying official and provide contact information.
Name: (Last)____________________(First)__________________(Middle)_____________
Title______________________________________________________________________
Street or P.O. Box______________________________________________________
City____________________County_________________State______________ZIP________-__________
Telephone (____)_____-__________ Ext._______ Facsimile (____)________-___________
e.mail address ___________________________________________

Certification of Truth, Accuracy and Completeness: The Certifying Official must sign this statement after the
form is completed.
I certify that, based on information and belief formed after reasonable inquiry, the statements and information
contained in these documents are true, accurate and complete.
Name (signed)________________________________________________________
Name (printed or typed)_______________________________________Date____/____/_______

Return completed forms and attachments to:
EPA Region 10 (OAWT)
FARR Registration Coordinator
Office of Air Waste and Toxics
1200 Sixth Avenue
Seattle, WA 98101

The public reporting and recordkeeping burden for this collection of information is estimated at
5.61 hours 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 7630-5

Page 5 of 6

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

FARR REGISTRATION APPLICATION INSTRUCTIONS
GENERAL INFORMATION
Identifying Information
FACILITY
Enter the name and the correct street address or other physical location of the facility (e.g. Acme Road or
Building 3, XYZ Industrial Park) together with telephone and facsimile numbers.
Provide a brief description of the nature of the business conducted by the facility.
Provide name of the Indian Reservation on which the facility is located.
Provide name and contact information for the facility contact person responsible for source compliance with
this rule.
OWNER / OPERATOR
Enter the name of the new owner and operator of the facility for which this application is being prepared. For
individual owners, list the full name (last, middle initial, first). For multiple ownership where no legal business
partnership exists, provide the name and mailing address, if different, of each individual owner using a
backslash (\) to separate data for each owner. For corporations, include divisions or subsidiary name, if any.
Enter the complete mailing address of the new owner and operator.
Provide name and contact information for the contact person authorized to receive requests for data and
information.
PROCEDURE FOR ESTIMATING EMISSIONS
The initial registration and annual registration must include an estimate of actual emissions taking into account
equipment, operating conditions, and air pollution control measures. For an existing air pollution source that
operated during the calendar year preceding the initial registration or annual registration submittal, the actual
emissions are the actual rate of emissions for the preceding calendar year and must be calculated using the
actual operating hours, production rates, in-place control equipment, and types of materials processed, stored, or
combusted during the preceding calendar year. For a new air pollution source that is submitting its initial
registration, the actual emissions are the estimated actual rate of emissions for the current calendar year. The
emission estimates must be based upon actual test data or, in the absence of such data, upon procedures
acceptable to the Regional Administrator. Any emission estimates submitted to the Regional Administrator
must be verifiable using currently accepted engineering criteria. The following procedures are generally
acceptable for estimating emissions from air pollution sources:
(i) Source-specific emission tests;
(ii) Mass balance calculations;
(iii) Published, verifiable emission factors that are applicable to the source;
(iv) Other engineering calculations; or
(v) Other procedures to estimate emissions specifically approved by the Regional Administrator.

EPA Form 7630-5

Page 6 of 6