Last updated: 12/1/2010
Air Permit Application Cover Sheet {50639}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
AIR PERMIT APPLICATION COVER SHEET State Form 50639 (R4 / 1-10) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDEM Office of Air Quality Permits Branch 100 N. Senate Avenue, MC 61-53 Room 1003 Indianapolis, IN 46204-2251 Telephone: (317) 233-0178 or Toll Free: 1-800-451-6027 x30178 (within Indiana) Facsimile Number: (317) 232-6749 www.IN.gov/idem NOTES: · The purpose of this cover sheet is to obtain the core information needed to process the air permit application. This cover sheet is required for all air permit applications submitted to IDEM, OAQ. Place this cover sheet on top of all subsequent forms and attachments that encompass your air permit application packet. Submit the completed air permit application packet, including all forms and attachments, to IDEM Air Permits Administration using the address in the upper right hand corner of this page. IDEM will send a bill to collect the filing fee and any other applicable fees. Detailed instructions for this form are available on the Air Permit Application Forms website. FOR OFFICE USE ONLY PERMIT NUMBER: ____ ______ __________ ____________ · DATE APPLICATION WAS RECEIVED: · · 1. Tax ID Number: PART A: Purpose of Application Part A identifies the purpose of this air permit application. For the purposes of this form, the term "source" refers to the plant site as a whole and NOT to individual emissions units. 2. Source / Company Name: 4. Billing Address: City: 5. Permit Level: Exemption Registration 3. Plant ID: TVOP PBR State: SSOA MSOP ZIP Code: FESOP 6. Application Summary: Check all that apply. Multiple permit numbers may be assigned as needed based on the choices selected below. Initial Permit Review Request Interim Approval Site Closure Renewal of Operating Permit Revocation of Operating Permit Relocation of Portable Source Emission Reduction Credit Registry From: Company Name Change Correction to Non-Technical Information Asphalt General Permit Alternate Emission Factor Request Acid Deposition (Phase II) Transition (between permit levels) Administrative Amendment: To: Change of Responsible Official Notice Only Change Other (specify): Modification: New Emission Unit or Control Device New Applicable Permit Requirement Prevention of Significant Deterioration Minor Source Modification Minor Permit Modification Other (specify): Modified Emission Unit or Control Device Change to Applicability of a Permit Requirement Emission Offset MACT Preconstruction Review Significant Source Modification Significant Permit Modification 7. Is this an application for an initial construction and/or operating permit for a "Greenfield" Source? 8. Is this an application for construction of a new emissions unit at an Existing Source? Yes Yes No No Continued on Next Page Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department Of Environmental Management Office Of Air Quality State Form 50639 (R4 / 1-10) Air Permit Application Cover Sheet Page 2 of 2 PART B: Pre-Application Meeting Part B specifies whether a meeting was held or is being requested to discuss the permit application. 9. Was a meeting held between the company and IDEM prior to submitting this application to discuss the details of the project? No Yes: Date: 10. Would you like to schedule a meeting with IDEM management and your permit writer to discuss the details of this project? No Yes: Proposed Date for Meeting: PART C: Confidential Business Information Part C identifies permit applications that require special care to ensure that confidential business information is kept separate from the public file. Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out in the Indiana Administrative Code (IAC). To ensure that your information remains confidential, refer to the IDEM, OAQ information regarding submittal of confidential business information. For more information on confidentiality for certain types of business information, please review IDEM's Nonrule Policy Document Air-031-NPD regarding Emission Data. 11. Is any of the information contained within this application being claimed as Confidential Business Information? No Yes PART D: Certification Of Truth, Accuracy, and Completeness Part D is the official certification that the information contained within the air permit application packet is truthful, accurate, and complete. Any air permit application packet that we receive without a signed certification will be deemed incomplete and may result in denial of the permit. For a Part 70 Operating Permit (TVOP) or a Source Specific Operating Agreement (SSOA), a "responsible official" as defined in 326 IAC 2-7-1(34) must certify the air permit application. For all other applicants, this person is an "authorized Individual" as defined in 326 IAC 2-1.1-1(1). I certify under penalty of law that, based on information and belief formed after reasonable inquiry, the statements and information contained in this application are true, accurate, and complete. Name (typed) Title Signature Date American LegalNet, Inc. www.FormsWorkFlow.com
Related forms
-
OAQ Process Information Application PI-17 Blasting Operations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-05 Brick And Clay Products
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02B Combustion Boilers Process Heaters And Furnaces
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02G Combustion Emission Factors
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02H Combustion Federal Rule Applicability
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02F Combustion Fuel Use
Indiana/Statewide/Department Of Enviromental Management/Air/ -
General Source Data Application GSD-14 Owners And Occupants Notified
Indiana/Statewide/Department Of Enviromental Management/Air/ -
General Source Data GSD-15 Government Officials Notified
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-02 Plant Layout Diagram
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-01 Basic Source level Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02D Combustion Incinerators And Combustors
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02E Combustion Kilns
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02C Combustion Turbines Reciprocating Internal Engines
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-02A Combustion Unit Summary
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-08 Concrete Batchers
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-09 Degreasing Operations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-10 Dry Cleaning Operations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-06 Electroplating
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-11 Foundry Smelting And Die Cast Operations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-12 Grain Elevators
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-04 Hot Or Cold Mix Asphalt Plants
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-13 Lime Manufacturing
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-18 Mineral Processing
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-01 Miscellaneous Processes
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-15 Portland Cement Manufacturing
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-16 Reinforced Plastics And Composites
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-21 Site Remediation
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-03 Storage And Handling Of Bulk Material
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-19 Surface Coating And Printing Operations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-14 Volatile Organic Liquid Compound Storage
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-07 Welding And Cutting Of Metal
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Process Information Application PI-20 Woodworking And Plastic Machining
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AEF-01 Alternate Emission Factor Request
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-03 Process Flow Diagram
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-04 Stack Vent Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-05 Emissions Unit Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-06 Particulate Emissions Summary
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-07 Criteria Pollutant Emissions Summary
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-08 Hazardous Air Pollutant Emissions Summary
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-09 Summary Of Additional Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-10 Insignificant Activities
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-11 Alternative Operating Scenario Summary
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ General Source Data Application GSD-12 Affidavit Of Nonapplicability
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Air Permit Application Cover Sheet
Indiana/Statewide/Department Of Enviromental Management/Air/ -
General Source Data Application GSD-13 Affidavit Of Applicability
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Air Permit Application Form Checklist
Indiana/Statewide/Department Of Enviromental Management/Air/ -
PAL-02 Revised Plantwide Applicability Limit
Indiana/Statewide/Department Of Enviromental Management/Air/ -
PAL-03 Plantwide Applicability Limit Renewal
Indiana/Statewide/Department Of Enviromental Management/Air/ -
PAL-04 Request For Termination Of Plantwide Applicability Limit
Indiana/Statewide/Department Of Enviromental Management/Air/ -
PAL-01 Actuals Plantwide Applicability Limit
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Individual Asbestos License
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Individual Lead License
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Lead Based Paint Training Course Provider Approval
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Lead Contractor
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Inital Notification Report Under Regulation 40 CFR Part 63 Subpart DDDDD
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Notification Of Demolition And Renovation Operations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Notification Of Lead Abatement Activities
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Registration Form For Lead Based Paint Third Party Examinations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Request For Use Of An Air Curtain Open Pit Destructor
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Request For Variance Form 326 IAC 4-1 Fire Training
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Request For Variance Form 326 IAC 4-1 Motor Vehicle Fire Training
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Request For Variance Form 326 IAC 4-1 Prescribed Vegetation Burn
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Request For Variance Form 326 IAC 4-1 Tree Waste Or Clean Wood Waste
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Duplicate Lead License
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application Checksheet For Asbestos Contractor
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Asbestos Contractor License
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Asbestos Training Course Provider Approval
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application For Duplicate Asbestos License
Indiana/Statewide/Department Of Enviromental Management/Air/ -
MACT-01 Pre Construction Review
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AES-03 Stack Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AES-04 Abatement Equipment
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AES-05 Group Process Emissions Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AES-06 Voluntary Hazardous Air Pollutant Reporting
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AES-01 Air Emission Statement Certification
Indiana/Statewide/Department Of Enviromental Management/Air/ -
AES-02 Facility General Information
Indiana/Statewide/Department Of Enviromental Management/Air/ -
CD-02 Compliance Plan Requirements Per Applicable Requirement
Indiana/Statewide/Department Of Enviromental Management/Air/ -
CD-03 Compliance Plan Requirements Per Emissions Unit
Indiana/Statewide/Department Of Enviromental Management/Air/ -
CD-04 Compliance Schedule And Certification
Indiana/Statewide/Department Of Enviromental Management/Air/ -
CD-01 Emissions Unit Compliance Status
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-05 Particulate Control Wet Collector Scrubber Absorption
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-06 Organics Flare Oxidizer Incinerator
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-07 Organics Adsorber
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-08 Organics Condenser
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-09 Nitrogen Oxides Reduction Technology
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-10 Miscellaneous Control Equipment
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-01 Control Equipment Summary
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-02 Particulate Control Baghouse Fabric Filter
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-03 Particulate Control Cyclone
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Control Equpiment Application CE-04 Particulate Control Electrostatic Precipitator
Indiana/Statewide/Department Of Enviromental Management/Air/ -
EC-03 Emission Credit Registry Use Of Emission Credits
Indiana/Statewide/Department Of Enviromental Management/Air/ -
EC-04 Emission Credit Registry Emission Credits Request
Indiana/Statewide/Department Of Enviromental Management/Air/ -
EC-01 Emission Credit Registry Generation Of Emission Credits
Indiana/Statewide/Department Of Enviromental Management/Air/ -
EC-02 Emission Credit Registry Transfer Of Emission Credits
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Identification Of Potentially Affected Persons
Indiana/Statewide/Department Of Enviromental Management/Air/ -
BACT 01A Background Search Existing BACT Determinations
Indiana/Statewide/Department Of Enviromental Management/Air/ -
BACT 01B Cost Economic Impact Analysis
Indiana/Statewide/Department Of Enviromental Management/Air/ -
BACT 02 Summary Of Best Available Control Technology
Indiana/Statewide/Department Of Enviromental Management/Air/ -
BACT 01 Analysis Of Best Available Control Technology
Indiana/Statewide/Department Of Enviromental Management/Air/ -
OAQ Permit Renewal Application Air Permit Renewal Checklist
Indiana/Statewide/Department Of Enviromental Management/Air/ -
Application Checksheet For Lead Contractor
Indiana/Statewide/Department Of Enviromental Management/Air/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!