**Notification of Compliance Status (NOCS) Report**

**\
**

**THIS IS A SAMPLE NOTIFICATION FORM, WHICH CAN BE USED BY FACILITIES\
AT THEIR DISCRETION TO MEET COMPLIANCE\
WITH 40 CFR 63 Subpart A, §63.9(h)**

Applicable Rule: 40 CFR Part 63, Subpart A --- National Emission
Standards for Hazardous Air Pollutants for Source Categories, Subpart A
--- General Provisions. This NOCS is being made in accordance with
§63.9(h).

Note: Notification of Compliance Status (NOCS) reports must be
postmarked before the close of business on the 60^th^ calendar day
following the completion of the relevant compliance demonstration
activity specified in the relevant standard, unless a different
reporting period is specified in the relevant standard. In the latter
case, the letter shall be postmarked before the close of business on the
day the report of the relevant testing or monitoring results is required
to be delivered or postmarked. Notifications may be combined as long as
the due date requirements are met for each notification.
\[§63.9(h)(2)(ii)\]

SECTION I\
GENERAL INFORMATION

A.  If you have been issued a Title V permit, do not complete this form.
    Submit your NOCS in accordance with your Title V permit.
    \[§63.9(h)(3)\]

B.  If you have not been issued a Title V permit, complete the remaining
    portions of this section and also complete Sections II-IX.
    \[§63.9(h)(2)(i)\]

C. Print or type the following information for each facility for which
you are making notification of compliance status:

  --------------------- ------- ------- ------- ------------ ------ ------ ------------------
  Operating Permit                              Facility                   
  Number (OPTIONAL)                             I.D. Number                
                                                (OPTIONAL)                 

                                                                           

  Responsible                                                              
  Official's Name/Title                                                    

                                                                           

  Street Address                                                           

                                                                           

  City                          State                        ZIP           
                                                             Code          

                                                                           

  Facility Name (if                                                        
  different from                                                           
  Responsible                                                              
  Official's Name)                                                         

                                                                           

  Facility Street                                                          
  Address (If different                                                    
  than Responsible                                                         
  Official's Street                                                        
  Address)                                                                 

                                                                           

  Facility Local                        Title                              Phone (OPTIONAL)
  Contact Name                                                             

                                                                           

  City                  State                                       ZIP    
                                                                    Code   

                                                                           
  --------------------- ------- ------- ------- ------------ ------ ------ ------------------

D. 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    Compliance Date (mm/dd/yy)
  standard or other requirement)           

  Sample Response. 40 CFR 63.753           Sample Response. 09/01/00
  ---------------------------------------- ------------------------------

# SECTION II

**CERTIFICATION** *(Note: you may edit the text in this section as
deemed appropriate)*

Based upon information and belief formed after a reasonable inquiry, I,
as a responsible official of the above-mentioned facility, certify the
information contained in this report is accurate and true to the best of
my knowledge. The above-mentioned facility \_\_\_\_\_\_\_\_\_\_\_
(has/has not) complied with the relevant standard or and other
applicable requirements referenced in the relevant standard.
\[§63.9(h)(2)(i)(G)\]

  ----------------------------- ------------------------- ----------------
  Name of Responsible Official  Title                     Date (mm/dd/yy)
  (Print or Type)                                         

                                                          

  Signature of Responsible                                
  Official                                                

                                                          
  ----------------------------- ------------------------- ----------------

> *Note: Responsible official is defined under §63.2 as any of the
> following: the president, vice-president, secretary, or treasurer of
> the company that owns the plant; the owner of the plant; the plant
> engineer or supervisor; a government official if the plant is owned by
> the Federal, State, city, or county government; or a ranking military
> officer if the plant is located on a military installation.*

**SECTION III**

Describe the methods you used to determine compliance.
\[§63.9(h)(2)(i)(A)\]

+-----------------------------------------------------------------------+
| Sample Response.                                                      |
|                                                                       |
| This facility used three spray gun cleaning compliance options as     |
| allowed under §63.744(c). These included using enclosed system        |
| cleaning, nonatomized cleaning, and disassembled gun cleaning. All of |
| the following methods were used to determine compliance:              |
|                                                                       |
| \(1\) Inspected spray gun cleaning areas to determine compliance with |
| allowable methods in §63.744(c)(1)-(4) and posted guidance on         |
| acceptable gun cleaning practices; (2) Performed monthly inspections  |
| on enclosed spray gun cleaners in accordance with §63.751(a),         |
| recorded results in accordance with §63.751(b)(5), and repaired       |
| detected leaks within 15 days or shut down operation in accordance    |
| with §63.744(c)(1)(ii).                                               |
+-----------------------------------------------------------------------+

# 

# SECTION IV

Describe the results of any performance tests, opacity or visible
emission observations, continuous monitoring system (CMS) performance
evaluations, and/or other monitoring procedures or methods that were
conducted. \[§63.9(h)(2)(i)(B)\]

+-----+------+--------+--------+--------+--------+--------+--------+
| Sam |      |        |        |        |        |        |        |
| ple |      |        |        |        |        |        |        |
| Res |      |        |        |        |        |        |        |
| pon |      |        |        |        |        |        |        |
| se. |      |        |        |        |        |        |        |
|     |      |        |        |        |        |        |        |
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| ity |      |        |        |        |        |        |        |
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| emi |      |        |        |        |        |        |        |
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| 40  |      |        |        |        |        |        |        |
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| 3.7 |      |        |        |        |        |        |        |
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| 63. |      |        |        |        |        |        |        |
| 751 |      |        |        |        |        |        |        |
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| ing |      |        |        |        |        |        |        |
| con |      |        |        |        |        |        |        |
| duc |      |        |        |        |        |        |        |
| ted |      |        |        |        |        |        |        |
| b   |      |        |        |        |        |        |        |
| etw |      |        |        |        |        |        |        |
| een |      |        |        |        |        |        |        |
| 9/1 |      |        |        |        |        |        |        |
| /00 |      |        |        |        |        |        |        |
| --  |      |        |        |        |        |        |        |
| 2/  |      |        |        |        |        |        |        |
| 28/ |      |        |        |        |        |        |        |
| 01: |      |        |        |        |        |        |        |
+-----+------+--------+--------+--------+--------+--------+--------+
| **  | **So | **R    | **R    | **R    | **R    | **R    | **R    |
| Sou | urce | esult\ | esult\ | esult\ | esult\ | esult\ | esult\ |
| rce | Lo   | (Sep   | (Oct   | (Nov   | (Dec   | (Jan   | (Feb   |
| I   | cati | 00)**  | 00)**  | 00)**  | 00)\   | 01)**  | 01)**  |
| D** | on** |        |        |        | **     |        |        |
+-----+------+--------+--------+--------+--------+--------+--------+
| C   | Bldg | 9/1 -- | 10/1   | 11/1   | 12/1   | 1/1 -- | 2/1 -- |
| LEA | 510, | OK no  | --     | -- OK  | -- OK  | OK no  | OK no  |
| N-1 | P    | leaks  | seal   | no     | no     | leaks  | leaks  |
|     | aint | de     | broke  | leaks  | leaks  | de     | de     |
|     | Shop | tected | (re    | de     | de     | tected | tected |
|     |      |        | paired | tected | tected |        |        |
|     |      |        | 10/10) |        |        |        |        |
+-----+------+--------+--------+--------+--------+--------+--------+
| C   | Ha   | 9/1 -- | 10/1   | 11/1   | 12/1   | 1/1 -- | 2/1 -- |
| LEA | ngar | OK no  | --     | --     | --     | OK     | OK no  |
| N-3 | 2    | leaks  | valve  | shut   | shut   | (re    | leaks  |
|     |      | de     | broke  | down   | down   | paired | de     |
|     |      | tected | (shut  |        |        | 12/31) | tected |
|     |      |        | down   |        |        |        |        |
|     |      |        | 10/13) |        |        |        |        |
+-----+------+--------+--------+--------+--------+--------+--------+

# SECTION V

Describe the methods you will use to determine continuous compliance,
including a description of monitoring and reporting requirements and
test methods. \[§63.9(h)(2)(i)(C)\]

+-----------------------------------------------------------------------+
| Sample Response.                                                      |
|                                                                       |
| This facility will determine continuous compliance with applicable    |
| requirements by continuing to use monitoring methods as identified in |
| Section III and Section IV. In addition, the facility plans to do the |
| following: (1) perform periodic unannounced inspections in areas      |
| where work practice measures were implemented; (2) submit periodic    |
| compliance reports signed by a responsible official in accordance     |
| with all applicable requirements in §63.753(b) -- spray gun cleaning. |
+-----------------------------------------------------------------------+

# SECTION VI

Describe the type and quantity of hazardous air pollutants (HAP) emitted
by the source (or surrogate pollutants if specified in the relevant
standard), reported in units and averaging times and in accordance with
the test methods specified in the relevant standard.
\[§63.9(h)(2)(i)(D)\]

+------------+-------------+-------------+-------------+-------------+
| Sample     |             |             |             |             |
| Response.  |             |             |             |             |
|            |             |             |             |             |
| The        |             |             |             |             |
| following  |             |             |             |             |
| hazardous  |             |             |             |             |
| air        |             |             |             |             |
| pollutants |             |             |             |             |
| (HAPs)     |             |             |             |             |
| were       |             |             |             |             |
| emitted by |             |             |             |             |
| affected   |             |             |             |             |
| sources at |             |             |             |             |
| this       |             |             |             |             |
| facility   |             |             |             |             |
| during the |             |             |             |             |
| period     |             |             |             |             |
| 9/1/00 --  |             |             |             |             |
| 2/28/01.   |             |             |             |             |
| Please     |             |             |             |             |
| note that  |             |             |             |             |
| this       |             |             |             |             |
| facility   |             |             |             |             |
| has chosen |             |             |             |             |
| to         |             |             |             |             |
| segregate  |             |             |             |             |
| out it's   |             |             |             |             |
| emissions  |             |             |             |             |
| according  |             |             |             |             |
| to it's    |             |             |             |             |
| affected   |             |             |             |             |
| sources    |             |             |             |             |
| (as        |             |             |             |             |
| defined by |             |             |             |             |
| the        |             |             |             |             |
| relevant   |             |             |             |             |
| standard)  |             |             |             |             |
| due to     |             |             |             |             |
| ease of    |             |             |             |             |
| reporting  |             |             |             |             |
| and        |             |             |             |             |
| rec        |             |             |             |             |
| ordkeeping |             |             |             |             |
| (by that   |             |             |             |             |
| we mean    |             |             |             |             |
| that is    |             |             |             |             |
| how we     |             |             |             |             |
| kept our   |             |             |             |             |
| records).  |             |             |             |             |
| \[Owners   |             |             |             |             |
| or         |             |             |             |             |
| operators  |             |             |             |             |
| may choose |             |             |             |             |
| other      |             |             |             |             |
| groupings  |             |             |             |             |
| of         |             |             |             |             |
| emission   |             |             |             |             |
| points\]   |             |             |             |             |
+------------+-------------+-------------+-------------+-------------+
| **Source   | **Source    | **Source    | **HAPs      | **HAPs      |
| ID**       | Location**  | De          | Used**      | Emitted     |
|            |             | scription** |             | (tons)**    |
+------------+-------------+-------------+-------------+-------------+
| CLEAN -- 1 | Bldg 510    | Spray gun   | Toluene;    | 0.068       |
|            |             | cleaning    | xylene;     |             |
|            |             | operations  | MEK,        |             |
|            |             |             | e           |             |
|            |             |             | thylbenzene |             |
+------------+-------------+-------------+-------------+-------------+
| CLEAN -- 3 | Hangar 2    | Spray gun   | Toluene;    | 0.227       |
|            |             | cleaning    | xylene;     |             |
|            |             | operations  | MEK,        |             |
|            |             |             | e           |             |
|            |             |             | thylbenzene |             |
+------------+-------------+-------------+-------------+-------------+

# 

# 

# SECTION VII

If the relevant standard applies to both major and area sources, present
an analysis demonstrating whether the affected source is a major source
(using the emissions data generated for this notification.
\[§63.9(h)(2)(i)(E)\]

+-----------------------------------------------------------------------+
| Sample Response.                                                      |
|                                                                       |
| As illustrated in Section VI, the emissions during the reporting      |
| period were below major source thresholds for affected sources        |
| subject to the relevant standard. This facility does not expect these |
| sources to emit HAPs in quantities greater than the major source      |
| thresholds. However, this facility is classified as a major source    |
| due to its potential plant-wide emissions of trichloroethylene in     |
| quantities greater than 10 tons per year.                             |
+-----------------------------------------------------------------------+

**SECTION VIII**

Describe the air pollution control equipment (or method) for each
emission point, including each control device (or method) for each
hazardous air pollutant and the control efficiency (percent) for each
control device (or method). \[§63.9(h)(2)(i)(F)\]

+----------+----------+----------+----------+------------+------------+
| Sample   |          |          |          |            |            |
| R        |          |          |          |            |            |
| esponse. |          |          |          |            |            |
|          |          |          |          |            |            |
| The      |          |          |          |            |            |
| f        |          |          |          |            |            |
| ollowing |          |          |          |            |            |
| p        |          |          |          |            |            |
| ollution |          |          |          |            |            |
| control  |          |          |          |            |            |
| e        |          |          |          |            |            |
| quipment |          |          |          |            |            |
| is used  |          |          |          |            |            |
| at       |          |          |          |            |            |
| affected |          |          |          |            |            |
| sources  |          |          |          |            |            |
| within   |          |          |          |            |            |
| this     |          |          |          |            |            |
| f        |          |          |          |            |            |
| acility. |          |          |          |            |            |
| Addit    |          |          |          |            |            |
| ionally, |          |          |          |            |            |
| this     |          |          |          |            |            |
| facility |          |          |          |            |            |
| uses     |          |          |          |            |            |
| other    |          |          |          |            |            |
| co       |          |          |          |            |            |
| mpliance |          |          |          |            |            |
| methods  |          |          |          |            |            |
| that do  |          |          |          |            |            |
| not      |          |          |          |            |            |
| involve  |          |          |          |            |            |
| using    |          |          |          |            |            |
| p        |          |          |          |            |            |
| ollution |          |          |          |            |            |
| control  |          |          |          |            |            |
| eq       |          |          |          |            |            |
| uipment. |          |          |          |            |            |
| These    |          |          |          |            |            |
| include  |          |          |          |            |            |
| using    |          |          |          |            |            |
| c        |          |          |          |            |            |
| ompliant |          |          |          |            |            |
| cleaners |          |          |          |            |            |
| and work |          |          |          |            |            |
| practice |          |          |          |            |            |
| st       |          |          |          |            |            |
| andards. |          |          |          |            |            |
+----------+----------+----------+----------+------------+------------+
| **Source | *        | **Eq     | **       | **Control\ | **HAPs\    |
| ID**     | *Source\ | uipment\ | Control\ | E          | Co         |
|          | Lo       | Type**   | Device** | fficiency\ | ntrolled** |
|          | cation** |          |          | **         |            |
+----------+----------+----------+----------+------------+------------+
| CLEAN -- | Bldg 510 | Gun      | Enclosed | Meets all  | Toluene;   |
| 1        |          | Cleaner  | system   | re         | xylene;    |
|          |          | #SV738   |          | quirements | MEK,       |
|          |          |          |          | of         | et         |
|          |          |          |          | §63.74     | hylbenzene |
|          |          |          |          | 4(c)(1)(i) |            |
+----------+----------+----------+----------+------------+------------+
| CLEAN -- | Hangar 2 | Gun      | Enclosed | Meets all  | Toluene;   |
| 3        |          | Cleaner  | system   | re         | xylene;    |
|          |          | #16104   |          | quirements | MEK,       |
|          |          |          |          | of         | et         |
|          |          |          |          | §63.74     | hylbenzene |
|          |          |          |          | 4(c)(1)(i) |            |
+----------+----------+----------+----------+------------+------------+

**SECTION IX**

A. Did you submit an application for construction or reconstruction
under §63.5(d) that contained preliminary or estimated data?
\[§63.9(h)(5)\]

Yes No Not applicable (did not submit an application for
construction or reconstruction).

B.  If you answered yes, provide actual emission data or other corrected
    information below.

  -----------------------------------------------------------------------

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**END OF FORM. *[A Responsible Official must sign this
form]{.underline}* -- See Section II.**