Inital Notification Report Under Regulation 40 CFR Part 63 Subpart DDDDD {51956}

INITIAL NOTIFICATION REPORT UNDER REGULATION 40 CFR Part 63, Subpart DDDDD State Form 51956 (10-04) National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters and 40 CFR Part 63, Subpart A, §63.9(b) General Provisions. This form is an example of how you can meet the requirement to submit an INITIAL NOTIFICATION REPORT under the following regulation: 40 CFR Part 63, Subpart DDDDD--National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters and 40 CFR Part 63, Subpart A, §63.9(b) General Provisions. This form is provided for your convenience. You are not required to use this form and may choose your own format to submit the required information. You must submit an Initial Notification not later than March 12, 2005, or within 120 calendar days after your boiler or process heater becomes subject to the National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters, whichever is later. Please send one copy to each of the following agencies: IDEM / Office of Air Quality Compliance Branch 100 N. Senate Avenue, P.O. Box 6015 Indianapolis, Indiana 46206-6015 George Czerniak (AE-17J) U.S. EPA, Region V 77 W. Jackson Blvd. Chicago, Illinois 60604 Application for Approval of Construction or Reconstruction. If your boiler or process heater will be a new or reconstructed major affected source, you are required by 40 CFR 63.5(d) to submit an Application for Approval of Construction or Reconstruction as soon as practicable before actual construction or reconstruction begins. If you are also required to submit an Initial Notification (not all new or reconstructed units are required to submit Initial Notifications), you may, as allowed under 40 CFR 63.9(b)(1)(iii), submit this Application for Approval of Construction or Reconstruction in lieu of an Initial Notification. If you choose to take advantage of this option, you must submit the Application for Approval of Construction or Reconstruction according to the time frames established in 40 CFR 63.5(d) instead of the time frames established for submitting Initial Notifications in 40 CFR 63.7545. Additionally, it is important to note that all sources that are new or reconstructed major affected sources must meet the requirements of 40 CFR 63.9(b)(4) in addition to complying with the requirements of 40 CFR 63.5(d). This form is being submitted in accordance with 40 CFR 63.9(b) and as required by 40 CFR 63.7545. If you own or operate an affected source, submit this report by MARCH 12, 2005, or WITHIN 120 CALENDAR DAYS after your boiler or process heater becomes subject to the National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters, whichever is later. Print or type the following information for each facility for which you are making initial notification: (§63.9(b)(2)(i)-(ii)) SECTION 1 GENERAL INFORMATION Operating Permit Number Facility I.D. Number (IF AVAILABLE) Responsible Official's Name/Title Street Address City/State/ZIP code Facility Name Facility Street Address (If different than Responsible Official's Street Address) Facility Local Contact Name City/State/ZIP code Title Phone Check the box that applies. (§63.9(b)(2)(v)) My facility is a major source of Hazardous Air Pollutants (HAP) My facility is an area source of HAP NOTE: A major source is a source that emits or has the potential to emit 10 tons per year, or more, of any one HAP or 25 tons per year, or more, of multiple HAP. All other sources are area sources. The major/area source determination is based on all HAP emission points inside the facility fence line, not just inside the facility itself. If you answered that your facility is an area source, the facility is not subject to this rule. Records of your applicability determination must be maintained on site for 5 years. See 40 CFR 63.10(b)(3). If you answered that your facility is a major source for HAP emissions, complete the remaining questions. American LegalNet, Inc. www.FormsWorkflow.com C. Indicate the relevant standard or other requirement that is the basis for this notification and the source's compliance date: (§63.9(b)(2)(iii)) Basis for this notification (relevant standard or other requirement) National Emission Standards for Hazardous Air Pollutants for Industrial, Commercial, and Institutional Boilers and Process Heaters (40 CFR Part 63, Subpart DDDDD) SECTION 2 SOURCE DESCRIPTION A. Briefly describe the nature, size, design, and method of operation of the source. (§63.9(b)(2)(iv)) NOTE: If the same information requested above is contained in a title V permit application or permit, you may attach the relevant pages from that document to this notification and reference those pages above. Anticipated Compliance Date (mm/dd/yy) B. Identify the types of emission points within the affected source subject to the relevant standard and the types of hazardous air pollutants emitted. (§63.9(b)(2)(iv)) Types of Emission Points NOTE: Boilers and process heaters are typically served by chimneys or stacks for flue gas release and dispersion. Types of HAP Emitted Check the boxes indicating the principal types of HAP emitted by the affected source (i.e., boilers and process heaters). Check all that apply. For example, coal and residual oil fired boilers or process heaters would typically emit all three types of HAP. Natural gas fired boilers or process heaters would typically emit organic HAP. Metal HAP (for example, arsenic, beryllium, cadmium, chromium, cobalt, lead, manganese, mercury, nickel, selenium) Organic HAP (for example, acetaldehyde, benzene, formaldehyde, toluene, xylenes) Acid gas HAP (for example, hydrogen chloride, hydrogen fluoride) SECTION 3 SPECIFIC REQUIREMENTS Section 63.7545(b)(2) requires you to include in this Initial Notification a signed statement indicating whether your affected source has a federally enforceable permit that limits the annual capacity factor to less than or equal to 10 percent. My facility has a federally enforceable permit that limits the annual capacity factor to less than or equal to 10 percent for the following boilers and process heaters. Use the facility identification number from section I.A. My facility does not have federally enforceable permit that limits the annual capacity factor for any individual