Draft Forms for Recordkeeping - 2782.01

OMB Control Number is 2009-NEW
Expiration Date: MM/DD/YYYY

The following forms are existing forms developed by the San Joaquin Valley Air Pollution Control District
(District), and currently available to the public for use for compliance with recordkeeping requirements in
District Rule 8051. These forms are being used as draft forms at the Proposed Rule stage which will be adapted
for use by EPA in this collection of information. EPA intends to collect the same information and will develop
EPA instruments for this Information Collection Request for the Final Rule.
Paperwork Reduction Act Burden Statement:
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq.
(OMB Control No. 2090-NEW). Responses to this collection of information are mandatory (Clean Air Act
Section 114(a)). An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The public reporting and
recordkeeping burden for this collection of information is estimated be 1 hour (30 minutes reporting and 30
minutes recordkeeping) per response. 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 to the
Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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.

OMB Control Number is 2009-NEW
Expiration Date: MM/DD/YYYY

Month:

Regulation VIII Record Keeping Form
FORM A – Area Water Application
Project
Location:

City:

Owner:
Contact
Person:

Address:

(Miles/
Acres)

Size:
City:

Title:

Zip:
Phone:

Watering Schedule
Use this form to document daily water applications at a single site by recording total gallons per day and number
of applications per day at a single area. Use additional forms, as necessary, for areas with different treatment
schedules.
Area treated:
Week

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

1
2
3
4
5

Area treated:
Week

Sunday

1
2
3
4
5

Retain for one year after project ends. Title V sources are required to retain for five
years after project ends.

OMB Control Number is 2009-NEW
Expiration Date: MM/DD/YYYY

Month:

Regulation VIII Record Keeping Form

FORM C: For Permanent / Long Term Dust Controls
Project
Location:
Owner:
Contact
Person:

City:
Address:

(Miles/
Acres)

Size:
City:

Title:

Zip:
Phone:

Permanent Activities
Describe the types of permanent dust controls implemented, the date, the activity, such as applying an
organic dust suppressant, gravel, paving or a trackout control device. Add comments such as the amount
used, where used, brand name.

Date

Dust Control Activity
Performed (Gravel, paving)

Comments: Type of material, application rate.

Comments:

Retain for one year after project ends. Title V sources are required to retain for five
years after project ends. Attach product information, maps and other specifications as
appropriate unless already addressed in an approved or verified Fugitive PM10
Management Plan.