United States Environmental Protection Agency OMB No. 2060-0445 

# Account Certificate of Representation

This form is required to establish an Authori zed Account Representative for compliance accounts under the NOx Budget Trading Program. For more informati on, see instructions on the reverse side of the form.
This submission is:



### ~ New



### ~ Revised Check this box if you are also the Designated Representative for this plant unde r the Acid Rain Program:



### ~ STEP 1 Identify the budget source(s) by plant name, State, and, if applicable, ORISPL code. Plant Name State ORIS Code

STEP 2 Enter requested information for the Authorized Account Representative (AAR). Name AAR ID Number (if known) Address

Phone Number Fax Number

E-mail Address (if available)

STEP 3 Enter requested information for the Alternate Authorized Account Representative, if applicable. Name AAR ID Number (if known)

Phone Number Fax Number

E-mail Address (if available)

STEP 4 Provide the name of every owner and operator of the budget sources at the plant. Identify the budget sources they own and/or operate by boiler ID#. Name 

# ~ Owner 

# ~ Operator

ID# ID# ID# ID# ID# ID#

ID# ID# ID# ID# ID# ID#

Name 

# ~ Owner 

# ~ Operator

ID# ID# ID# ID# ID# ID#

ID# ID# ID# ID# ID# ID#

Name 

# ~ Owner 

# ~ Operator

ID# ID# ID# ID# ID# ID#

ID# ID# ID# ID# ID# ID#Plant Name (from Step 1) Account Certificate of Representation - Page 2

STEP 5 Read the certification, sign and date. I certify that I was selected as the NOx authorized account representative or alternate NOx authorized account representative, as applicable, by an agr eement binding on the owners and operators of the NOx Budget source and each NOx Budget unit at the source. I certify that I have all the necessary authority to carry out my duties and responsibilities under the NOx Budget Trading Program on behalf of the owners and operators of the NOx Budget source and of each NOx Budget unit at the source and that each such owner and operator shall be fully bound by my repres entations, actions, inactions , or submissions and by any decision or order issued to me by the permitting authority, the Administrator, or a court regarding the source or unit. I am authorized to make this submission on behalf of the owners and operators of the NOx Budget sources or NOx Budget units for which the submission is made I certify under penalty of law that I have personally examined, and am familiar with, the statem ents and information submitted in this document all its attachments. Based on my inquiry of those i ndividuals with primary responsibility for obtaining the information, I certify that the statem ents and information are to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant penalties for submitting false statements and information or omitting required statements and in formation, including the possibility of fine or imprisonment

.

Signature (Authorized Account Representative) Date

Signature (Alternate Authorized Account Representative) Date



## INSTRUCTIONS
Under the state regulations to implement the NOx Budget Tradi ng Program, the owners and operators for each budget source must d esignate a representative, and may designate an alternate, to act on their behalf. The owners and operators should choose the representative through a pr ocess that ensures that all owners and operators have notice regarding the selection. All budget sources at a plant must ha ve the same Authorized Account Represe ntative. The Authorized Account Representative is responsible for all submissions and allowance transactions relating to the budge t sources at that plant. The Authorized Account Representative and the Alternate Authorized Account Representative are li able for acts or omissions within th e scope of their responsibilities under the NOx Budget Trading Program. EPA will not record an allowance transaction until it has received a complete Account Certificate of Representation.

Please type or print. If more space is needed, photocopy the first page. Indicate the page order and total number of pages ( e.g. , 1 of 4, 2 of 4, etc.). Note : An Account Certificate of Representation amending an earlier submission supersedes the earlier submission in its entirety . A revised Account Certificate of Represen tation must therefore be complete , including signature and dating by the Authorized Account Representative (and the Alternate, if applicable). Submit one Account Certificate of Representation form with original signatures. Remember that the Authorized Account Representative should notify each owner and operator of all NOx Budget Program submissions. For assistance, call the EPA’ s Clean Air Markets Division Hotline at (202) 343-9620. STEP 1: If any budget source at the plant is affected by the Acid Rain Program, the ORISPL code is embedded in the first six digits of the unit account number for that source under the Acid Rain Program. If there are not any budget sources at the plant affected by the Acid Rain Program, a budget source should use the plant or facility code registered with the Department of Energy (DOE) to obtain an ORISPL code. (For utilities reporting on the EIA-767, -860, and -861, the plant code would be used as the ORISPL code. For nonutilities reporting on the EIA-867, the facility code would be used as the (ORISPL code). If the budget source does not report to DOE, and therefore does not have an ORISPL code, the budget source should call the Acid Rain Program Hotline for assistance. STEP 2 : The Authorized Account Representative must be a natural person and cannot be a company. Please enter the firm name and address as it should appear on all correspondence.
EPA Form 7620-16 Representative must rely on the Authorized Account Representative to forward information mailed by EPA. STEP 4 The owners and operators may be companies or natural persons. Identify each budget source at the plant that is owned or operated by the named party by providing the unit identification number for the budget source. If a budget source is affected by the Acid Rain Program, the source should determine an appropriate ID# that it will use for all NOx Budget Trading Program purposes. This ID# must be six digits or less. STEP 5 Note the certification statement.
SUBMISSION INSTRUCTIONS: Submit this form prior to submission of the monitoring plan for the NOx Budget Trading Program. This form must be submitted before participating in transfers of allowances. Submit a revised Account Certificate of Representation when any information in the existing Account Certificate of Representation changes. Mailing Instructions Mail this form to EPA at one of the following addresses: U.S. EPA NOx Budget Trading Program (6204J) for regular or certified mail: for overnight mail: 1200 Pennsylvania Ave, NW 1310 L Street, NW Washington, DC 20460 Washington, DC 20005 Phone: 202-343-9620Paperwork Burden Estimate The public reporting and record keeping burden for this collecti on of information is estimated to average30 hours per response . Burden means the total time, effort, or financial resour ces expended by persons to generate, maintain , retain, or disclose or provide inform ation to or for a Federal agency. This includes the time needed to review inst ructions; develop, acquire, install, and utilize technology and sy stems for the purposes of collecting, validating, and ve rifying information, processing and mainta ining information, and disclosing and provi ding information; adjust the existing ways to comply with any previ ously applicable instructions and requirements; train personnel t o be able to respond to a collection of information; search data sources; comp lete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or spons or, and a person is not required to respond to, a collection of in formation unless it displays a currently valid OMB control number. Send comments on the Agency's need for this information, the accu racy of the provided burden estimates, and any suggested metho ds for minimizing respondent burden, including through the use of automa ted collection techniques to the Director, Collection Strategi es Division, U.S. Environmental Protection Agency (2822), 1200 Pennsylvania Av e., NW., Washington, D.C. 20460. Include the OMB control numb er in any correspondence. Do not send the completed form to this address.