### OMB Control No. 2060-0003 Approval expires 04/30/2012

EPA Form No. 5900-247 United States Environmental Protection Agency Program
Address

Phone
Fax
Web address Reviewing Authority Program
Address

Phone
Fax
Web address



### FEDERAL MINOR NEW SOURCE REVI EW PROGRAM IN INDIAN COUNTRY



## Registration for Existing Sources
(FORM REG)

Please submit information to:



### [Reviewing Authority
Address Phone]

A. GENERAL SOURCE INFORMATION
1. Company Name 2. Source Name

3. Type of Operation 4. Portable Source? Yes No 5. Temporary Source? Yes No

6. NAICS Code 7. SIC Code

8. Physical Address (home base for portable sources)

9. Reservation* 10. County* 11a. Latitude* 11b. Longitude*

12a. Quarter-Quarter Section * 12b. Section* 12c. Township* 12d. Range*

* Provide all locations of operation for portable sources

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### B. CONTACT INFORMATION

1. Owner Name Title

Mailing Address

Email Address

Telephone Number Facsimile Number

2. Operator Name (if different from owner) Title

Mailing Address

Email Address

Telephone Number Facsimile Number

3. Source Contact Title

Mailing Address

Email Address

Telephone Number Facsimile Number

4. Compliance Contact Title

Mailing Address

Email Address

Telephone Number Facsimile Number

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### C. ATTACHMENTS

Include all of the following informat ion as attachments to this form

Narrative description of the operations

Identification and description of all emission units and air pollution generating activities (with the exception of the exempt emissions units and activities listed in §49.153(c)

Identification and description of any existing air po llution control equipment and compliance monitoring
devices or activities

Type and amount of each fuel used

Type raw materials used

Production Rates

Operating Schedules

Any existing limitations on source operations affecting emissions or any work practice standards, where applicable, for all regulated NSR pollutants at your source.

Total allowable (potential to emit if there are no legally and practically enforceable restrictions) emissions from the air pollution source for the following air pollutants: particulate matter, PM 10, PM 2.5, sulfur oxides (SO x ), nitrogen oxides (NO x ), carbon monoxide (CO), volatile organic com pound (VOC), lead (Pb) and lead compounds, fluorides (gaseous and particulate), sulfuric acid mist (H 2 SO 4 ), hydrogen sulfide (H 2 S), total reduced sulfur (TRS) and reduced sulfur compounds, includin g all calculations for the estimates.

Estimates of the total actual emissions from the air pollu tion source for the following air pollutants: particulate matter, PM 10, PM 2.5, sulfur oxides (SO x ), nitrogen oxides (NO x ), carbon monoxide (CO), volatile organic compound (VOC), lead (Pb) and lead compounds, ammonia (NH 3 ), fluorides (gaseous and particulate), sulfuric acid mist (H 2 SO 4 ), hydrogen sulfide (H 2 S), total reduced sulfur (TRS) and reduced sulfur compounds, including
all calculations for the estimates.

Other

[ Disclaimers ] The public reporting and recordkeeping burden for this collection of information is estimated to average 6 hours per response. Send comments on the Agen cy’s need for this information, the accuracy of the provided burden estimates, and any suggested me thods 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.

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### D. TABLE OF ESTIMATED EMISSIONS

The following estimates of the total emissions in tons/year for all pollu tants contained in your worksheet stated above should be provided.

Pollutant Total Actual Emissions (tpy) Total Allowable or
Potential Emissions (TPY)

PM

PM 10

PM 2.5

SO

x

NO

x

CO

VOC

Pb

NH 3

Fluorides H 2 SO 4

H 2 S

TRS

RSC



### Emissions calculations must include fugitive em issions if the source is one the following listed sources, pursuant to CAA Section 302(j):

(a) Coal cleaning plants (with thermal dryers); (b) Kraft pulp mills; (c) Portland cement plants; (d) Primary zinc smelters; (e) Iron and steel mills; (f) Primary aluminum ore reduction plants; (g) Primary copper smelters; (h) Municipal incinerators capa ble of charging more than 250 tons of refuse per day; (i) Hydrofluoric, sulfuric , or nitric acid plants; (j) Petroleum refineries; (k) Lime plants; (l) Phosphate rock processing plants; (m) Coke oven batteries; (n) Sulfur recovery plants; (o) Carbon black plan ts (furnace process); (p) Primary lead smelters; (q) Fuel conversion plants; (r) Sintering plants; (s) Secondary metal production plants; (t) Chemical process plants (u) Fossil-fuel boilers (or combination thereof) totaling more than 250 million British thermal units per hour heat input; (v) Petroleum storage and tr ansfer units with a total storage capacity exceed ing 300,000 barrels; (w) Taconite ore processing plants; (x) Glass fiber processing plants; (y) Charcoal production plants; (z) Fossil fuel-fired steam electric plants of more that 250 million British thermal units per hour heat input,
and (aa) Any other stationary source category which, as of August 7, 1980, is being regulated under section 111
or 112 of the Act.

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## Instructions

Please answer all questions. If the item does not appl y to the source and its ope rations write “n/a”. If
the answer is not known write "unknown".

A. General Source Information

1. Company Name : Provide the complete company name. For co rporations, include divisions or subsidiary name, if any.

2. Source Name : Provide the source name. Please note that a source is a site, place, location, etc... that may contain one or more air pollution emitting units.

3. Type of Operation : Indicate the generally accepted name for the ope ration (i.e., asphalt plant, gas station, dry cleaner, sand & gravel mining, oil and gas well site, tank battery, etc.).

4. Portable Source : Does the source operate in more than one location? Some examples of portable sources include asphalt batch plants and concrete batch plants.

5. Temporary Source : A temporary source, in general, would have emissions that are expected last less than 2 years. Do you expect to cease operations within the next 2 years?

6. NAICS Code: North American Industry Classification System. The NAICS Code for your source can be found at the following link  North American Industry Classification System ( http://www.census.gov/epcd/naics/nsic2ndx.htm#S1 ).

7. SIC Code : Standard Industrial Classification Code. Although the new North American Industry Classification System (NAICS) has replaced the SIC c odes, much of the Clean Air Act permitting processes
continue to use these codes. The SIC Code fo r your source can be found at the following link  Standard
Industrial Classification Code ( http://www.osha.gov/pls/imis/sic_manual.html ).

8. Physical Address : Provide the actual address of where the s ource is operating, not the mailing address.
Include the State and the ZIP Code.

9. Reservation : Provide the name of the Indian reservati on within which the source is operating.

10. County : Provide the County within which the source is operating.

11a & 11b. Latitude & Longitude : These are GPS (global positioning system) coordinates. This information can be provided in decimal format or degree-minute-second format.

12a – 12d. Section-Township-Range : Please provide these coordinates in Quarter-Quarter Section/Section/Township/Range. (e.g., SW 1⁄4, NE 1⁄4 /S36/T10N/R21E).

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### B. Contact Information

Please provide the information requested in full.

1. Owners : List the full name (last, middle initial, first) of all owners of the source.

2. Operator : Provide the name of the operator of the source if it is different from the owner(s).

3. Source Contact : The source contact must be the local contact authorized to receive requests for data and
information.

4. Compliance Contact : The compliance contact must be the lo cal contact responsible for the source’s compliance with this rule. If this is the same as the Source Contact please note this on the form.



### C. Attachments

The information requested in the attachment s will enable EPA to understand the type of source being registered and the nature and extent of the air pollutants being emitted.

D. Total Emissions

1. Allowable Emissions (See also, Potential to Emit) : Emissions rate of a source calculated using the maximum rated capacity of the source (unless the source is subject to practically and legally enforceable limits which restrict the operating rate, or hours of operation, or both) and the most stringent of the following:

a) Any applicable standards as set forth in 40 CFR parts 60 and 61;

b) Any applicable Tribal or Federal Implementation Plan emissions limitation, including those with a future compliance date; or

c) Any emissions rate specified as a fede rally enforceable permit condition, including those with a future compliance date.

2. Potential to Emit : The maximum capacity of a source to emit a pollutant under its physical and operational design. Any physical or opera tional limitation on the capacity of the source to emit a pollutant, incl uding air pollution control equi pment and restrictions on hours of operation or on the type or amount of material combusted, stored, or processed, shall be treated as part of its design if th e limitation or the effect it would have on emissions is enforceable as a practi cal matter. See Allowable Emissions.

Actual Emissions : Estimates of actual emissions must ta ke into account equipment, operating conditions, and air pollution control measures. Fo r a source that operated during the entire calendar year preceding the initial registration submittal, the reported actual emissions typically should be the annual emissions for the preceding calendar year , calculated using the actual operating hours, production rates, in-place control equipment, and ty pes of materials processed, stored, or combusted during the preceding calendar year. However, if you believe that the actual emissions in the preceding calendar year are not representative of the emissions that your source will actually emit in coming

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Page 7 of 7 years, you may submit an estimate of projected act ual emissions along with the actual emissions from the preceding calendar year and the rationale for the projected actual emissions. For a source that has not operated for an entire year, the actual emissions are the estimated annual emissions for the current calendar year.


### 3. The emission estimates can be based upon actual te st data or, in the absence of such data, upon procedures acceptable to the Reviewing Authority. The following procedures are generally acceptable for estimating em issions from air pollution sources:

(i) Source-specific emission tests; (ii) Mass balance calculations; (iii) Published, verifiable emissi on factors that are applicable to the source. (i.e., manufacturer specifications). (iv) Other engineering calculations; or (v) Other procedures to estimate emissions spec ifically approved by the Reviewing Authority.

4. Guidance for estimating emissions can be found at http://www.epa.gov/ttn/chief/efpac/index.html

.