Form 5800-057 Initial or Annual Source Registration

OMB Control No. 2060-NEW Expiration Date: XX/XX/XXXX

United States Environmental Protection Agency Region 10 Federal Air Rules for Indian
Reservations Initial / Annual Source Registration
Applicability: Air pollution sources regulated by 40 Code of Federal Regulations Part 49.138.
INSTRUCTIONS: Complete applicable parts of Sections A, B, C and D.
A. GENERAL INFORMATION
Report Type:
Report Year:
Source (Facility) Name:
Indian Reservation Name:
Air Quality Operating Permit:
Nature of the Business:

NEW

Facility Contact
First Name:
Telephone:
Facsimile:
Street (or PO BOX #):
City:
State:

Last Name:
Ext:
Email:
Addr Cont.:
County:
Zip:

Compliance Contact
First Name:
Telephone:
Facsimile:
Street (or PO BOX #):
City:
State:

Last Name:
Ext:
Email:
Addr Cont.:
County:
Zip:

Owner
First Name:
Telephone:
Facsimile:
Street (or PO BOX #):
City:
State:

Last Name:
Ext:
Email:
Addr Cont.:
County:
Zip:

Owner Contact
First Name:
Telephone:
Facsimile:

Last Name:
Ext:
Email:

EPA Form 5800-057

Street (or PO BOX #):
City:
State:

Addr Cont.:
County:
Zip:

Operator
First Name:
Telephone:
Facsimile:
Street (or PO BOX #):
City:
State:

Last Name:
Ext:
Email:
Addr Cont.:
County:
Zip:

Operator Contact
First Name:
Telephone:
Facsimile:
Street (or PO BOX #):
City:
State:

Last Name:
Ext:
Email:
Addr Cont.:
County:
Zip:

B. ATTACHMENTS
Instructions
Include all of the following information as attachments to this form
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
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
EPA Form 5800-057

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. Information claimed as
confidential should be submitted on CD or flash drive and mailed to FARR Registration Coordinator,
EPA Region 10, AWT-150, 1200 Sixth Ave., Suite 900, Seattle, WA 98101. Confidential treatment is
automatically forfeited for information submitted via this FARR Online Reporting System. 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.
Attachment Type File Name File Name File Size (Bytes) One item found.
C. TABLE OF ANNUAL EMISSIONS
Pollutant
PM
PM10
PM 2.5
SOx
NOx
CO
VOC
Pb
NH3
Fluorides
H2SO4
H2S
TRS
RSC

Definition of Acronym
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

Total Emissions

D. OWNER OR OPERATOR CERTIFICATION OF TRUTH, ACCURACY AND COMPLETENESS
Submitter
First Name:
Telephone:
Facsimile:
Street (or PO BOX #):
City:
State:

Last Name:
Ext:
Email:
Addr Cont.:
County:
Zip:
EPA Form 5800-057

Certifier
First Name: Middle Name:
Last Name :
Address:
State:
Phone:
Email:

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.
Review Information
Submission Certified on
Status:
Comments:

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EPA Form 5800-057