### EPA Form 5900-04 OMB No. 2060-0336, Approval Expires 04/30/2012 

### Federal Operating Permit Pr ogram (40 CFR Part 71)

ANNUAL COMPLIANCE CERTIFICATION (A-COMP)

A. GENERAL INFORMATION

Permit No. ____________________

Reporting Period: Beg.____/____/________ End.____/____/_______

Source / Company Name ___________________________________________________________

Mailing Address: Street or P.O. Box ________________________________________________

City ________________________________________ State______ ZIP__________ - ______

Contact person __________________________________ Title ___________________________

Telephone (______) ______ - __________ Ext. ________



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EPA Form 5900-04 2

B. COMPLIANCE STATUS

Describe the compliance status of each permit term for the reporting period. Copy this page as many times as necessary to cover all permit terms and conditions.

Emission Unit ID(s):

Permit Term (Describe requirements and cross-reference)

Compliance Methods for the Above (Description and Citation):

Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance

Emission Unit ID(s):

Permit Term (Describe requirements and cross-reference)

Compliance Methods for the Above (Description and Citation):

Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance

Emission Unit ID(s):

Permit Term (Describe requirements and cross-reference)

Compliance Methods for the Above (Description and Citation):

Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance

Emission Unit ID(s):

Permit Term (Describe requirements and cross-reference)

Compliance Methods for the Above (Description and Citation):

Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance

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EPA Form 5900-04 3

C. DEVIATIONS FROM PERMIT TERMS AND CONDITIONS

Report all deviations from permit terms (whether repor ted previously or not) that occurred during the permit term. Cross-reference deviations already repor ted in the six-month report. Indicate whether each

deviation is a A possible exception @ to compliance. @ Start and end period of each deviation should be in mo/day/yr, hr:min format (24-hour clock). Also specify the date when the written deviation report was submitted (If written report required, but not submitted, leave the date field blank).

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

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EPA Form 5900-04 4

INSTRUCTIONS FOR A-COMP

ANNUAL COMPLIANCE CERTIFICATION

Information Collection Burden Estimates

The public reporting and recordkeeping burden for this collection of information is estimated to average 221 hours per respondent per year. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

DETAILED INSTRUCTIONS

Submit this form along with a certification of truth, accuracy and completeness by a responsible official on

an annual basis.

Section A (General Information)

Name and address should be consistent with information provided previously. The contact person should be a person familiar with the day-to-day operation of the facility, such as a plant site manager or other individual, who should be available to be contacted by the permitting authority. If there is more than one contact person, list the others on an attachment.

The reporting period must be at least every 12 months, but your permit may require this more frequently.

Section B (Compliance Status)

Description of Permit Term : Include each permit terms that imposes a requirement or action (emission limitations, standards, monitoring, recordkeeping, reporting, and other requirements on one or more emission units or on the facility. You will likely have to complete this section numerous times to include all requirements in the permit.

The emissions unit ID(s) should be those defined in the permit or in section I of form GIS. If the requirements, including compliance methods, apply in t he same way to multiple emission units, you may list multiple units for a particular requirement. Emission units and requirements may be grouped if they apply the same way at all units in the group, the same compliance methods apply to all, and all units have the same compliance status.

Citations to the requirements should unambiguously identify the permit term to the lowest level.

Compliance Methods : List all compliance methods (monitoring, recordkeeping and reporting) youused to determine compliance with the permit term described above. Also describe and crossreference these compliance methods.

To describe monitoring, indicate the monitoring dev ice, what is being monitored, averaging time, frequency, and cross-reference the permit term. To describe recordkeeping, describe the records kept, collection frequency, and cross-reference the permit term. Please indicate whether monitoring data, results, or if compliance records are be kept on-site rather than reported. To describe reporting requirements, describe what is reported, when it is reported, and cross-reference the permit term.

The citation or cross-reference here must unambiguously identify the requirement to the lowest level.

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EPA Form 5900-04 5

Compliance Status : For each permit requirement and its associated compliance methods, indicate whether there was intermittent or continuous compliance (check one) during the reporting period. You

should consider all available information or k nowledge that you have when evaluating this, including compliance methods required by the permit and A credible evidence @ (e.g., non-reference test methods

and information A readily available @ to you). You are always free to include written explanations and other information to clarify your conclusion regarding compliance status.

You must include permit terms that were not effective or not applicable (e.g., future-effective requirements, compliance options, and alternative scenarios). You may certify to continuous compliance for these if there is no evidence of noncompliance.

Absent evidence to the contrary, you may certify continuous compliance based on the data provided by the compliance methods, provided you did not fail to perform them and there were no unexcused deviations. Any failure to meet any permit term for any period of time indicates intermittent compliance. You may also indicate “undetermined compliance,” if you include the reason.

Section C (Deviations From Permit Terms and Conditions)

Summarize all deviations from permit terms that occurred since the last compliance certification. They may have been reported previously in-writing or they may be r eported concurrently with this certification. Also include any deviations but have not yet been reported in writing.

Copy this page as many times as necessary to in clude all deviations that occurred during the reporting period for this compliance certification.

Deviations occur when any permit term is not met, including emission limitations, standards, monitoring, recordkeeping, reporting and other requirements. For a more detailed explanation of the term

A deviation, @ see the instructions for Form SIXMON . A deviation is not necessarily a violation. Violations are determined by EPA (or its delegate Agency).

You may cross-reference deviations previously reported (e.g., in 6-month monitoring reports).

You must indicate whether each deviation is a A possible exception to compliance. @ This is a deviation that occurs when compliance is required. A deviation that is not a “possible exception to compliance” is one that occurs when compliance is not required or it is excused by another permit term. If you indicate that a deviation is not a possible exception to compliance, briefly explain and cross-reference the permit

term that allows or excuses it. Also, deviations fo r which the permit provides an affirmative defense (e.g., emergencies) must be identified as “possible exception to compliance” because only the permitting authority may determine if the affirmative defense applies.

If the cross-reference a deviation report that does not contain all the information requested here, you must supplement it accordingly.

You may list multiple emission units if they all had the same deviation during the same time periods. In addition, for deviations that impose requirements to the permitted facility as a whole or to all units at your facility, you may enter A facility-wide @ in the emissions unit column.

You may indicate continuous periods of deviation that span multiple days in a single entry. Use the 24- hour clock (equivalent to military time) for reporting these times (e.g., the day starts and ends at midnight, 12 a.m., or 00:00 in military time.

Specify the date when the written deviation report was submitted to the permitting authority. Leave the date field blank if you did not submit a written dev iation report during the reporting period covered by the six-month monitoring report (whether required to do so or not). It is a deviation to fail to submit a required

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EPA Form 5900-04 6

deviation report.

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EPA Form 5900-04 7

Form CTAC (Certification of Truth, Accuracy, and Completeness by Responsible Official)

You must complete form CTAC and attach it to this annual compliance certification.