Part 1 Title V Application
Sources Subject to Section 112(j) Provisions
40 CFR 63.50 through 63.56
1) Source Name
2) Source ID No.
3) Street Address
7) Zip Code
Mailing Address (if different than physical location)
12) Zip Code
13) Is your facility a major source of hazardous air pollutants (HAP)? If not,
you need not complete the rest of this form.
A major source is any contiguous area under common control that emits or
has the potential to emit considering controls, in the aggregate, at least 10
tons per year of any single HAP or 25 tons per year total HAP.
14) Do you own or operate an affected source in a source category for which
EPA has not promulgated standards under 40 CFR 63? If so, which one(s)?
If not, you need not complete the rest of this form.
(See Table of Promulgated Regulations, Table of Proposed Regulations, and
Table of Upcoming Regulations at www.epa.gov/ttn/atw/eparules.html to
determine if your standard has not been promulgated.)
15) Provide a brief description of the major source and its activities:
16) Provide a brief description of the affected source(s) in the relevant source category(ies):
17) Identify any sources that have MACT determinations under section 112(g):
Certification and Signature of Responsible Official
18) I certify that the information contained in this application to be accurate and true to the
best of my knowledge:
Printed name of Signatory Date