DEPARTMENT OF ENVIRONMENTAL 

CONSERVATION

Standard Permit Condition XVI – Emission Inventory 

Reporting Form

Permit Condition for Air Quality Permits

Adopted by Reference in 18 AAC 50.346

September 27, 2010
Standard Permit Condition XVI – Emission Inventory Reporting Form September 27, 2010

2

ADEC Reporting Form

Emission Inventory Reporting

State of Alaska Department of Environmental Conservation

Division of Air Quality

Emission Inventory Year- [ ]

Mandatory information is highlighted.

Inventory start 

date: 

Inventory end date: 

Inventory Type:

Facility Information:

ADEC Stationary Source ID: 

(Stationary Source) Facility 

Name: 

AFS ID: 

Census Area/ Community: 

Line of Business (NAICS): 

Contact/Owner Name: 

Contact Owner Address:

Contact/Owner Phone 

Number:

Facility Physical Address: 

Lat: Long:

Mailing Address :

Emission Unit:

ID:

Description: 

Manufacturer: 

Model Number: 

Serial Number: 

Year of Manufacture: 

Maximum Nameplate 

Capacity:

Design Capacity (BTU/hr): 

Control Equipment (List 

All): 

Control Equipment Type(Primary or Secondary): 

ID:

Type:

Manufacturer: 

Model: 

Control Efficiency (%): 
Standard Permit Condition XVI – Emission Inventory Reporting Form September 27, 2010

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Capture Efficiency (%): 

Total Capture Efficiency (%): 

Pollutants Controlled

-

-

-

-

Processes (List 

All): 

PROCESS: 

SCC Code:

Material Processed: 

Operational Periods: 

FUEL INFORMATION

Ash Content (weight %):

Elem. Sulfur Content (weight %):

H2S Sulfur Content (ppmv): 

Heat Content (MMBtu/1000 gal or MMBtu/MMscf):

Heat Input (MMBtu/hr): 

Heat Output (MMBtu/hr): 

THROUGHPUT

Total Amount: 

Summer %: 

Fall %: 

Winter %: 

Spring %: 

Days/Week of Operation: 

Weeks/Year of Operation: 

Hours/Day of Operation: 

Hours/Year of Operation: 
Standard Permit Condition XVI – Emission Inventory Reporting Form September 27, 2010

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EMISSIONS

Pollutant

Emission 

Factor

Emission 

Factor 

Numerator

Emission 

Factor 

Denominator

Emission 

Factor 

Source

Tons 

Emitted

CO

NH3

NOX

PM10-PRI

PM25-PRI

SO2

VOC

Lead and lead 

compounds

Stack 

Description: 

Stack Detail:

ID: 

Type: 

Measurement Units: 

Base Elevation: 

Stack Height: 

Stack Diameter: 

Exit Gas Temp: 

Exit Gas Velocity: 

Actual Exit Gas Flow Rate: 

Data Source: 

Description: 

Latitude: 

Longitude: 

Location Description: 

Accuracy (m): 

Datum: 

Certification:

Based on information and belief formed after reasonable inquiry, I certify that the statements and 

information in and attached to this document are true, accurate, and complete.

Printed Name:______________________________Title_____________________Date ______

Signature:_________________________________ Phone number_______________________
Standard Permit Condition XVI – Emission Inventory Reporting Form September 27, 2010

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NOTE: This document must be certified in accordance with 18 AAC 50.345(j)

To Submit this report:

1. Fax this form to: 907-465-5129

Or

2. E-mail to: DEC.AQ.airreports@alaska.gov

Or

3. Mail to: ADEC

Air Permits Program

410 Willoughby Ave., Suite 303

PO Box 111800

Juneau, AK 99801-1800

Or

4. Submission of information can be made via a full electronic batch submittal (XML files). 

This will require each data element to be tagged with XML (Extensible Markup Language)

code before it can be uploaded to ADEC database. 

https://myalaska.state.ak.us/dec/air/airtoolsweb/EiXmlValidator.aspx