EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

United States Environmental Protection Agency

Air Quality Permit by Rule for New or Modified True Minor Sources of 

Air Pollution in Indian Country

http://www.epa.gov/air/tribal/tribalnsr.html

Notification of Coverage: Gasoline Dispensing Facilities Page 1 of 10

Version 1.0

Notification of Coverage under the Air Quality Permit by Rule for New or Modified 

True Minor Source Gasoline Dispensing Facilities in Indian Country

Last Modified: March 23, 2015

Version 1.0

This Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline 

Dispensing Facilities in Indian Country applies to the construction of new, true minor source gasoline dispensing 

facilities or the modification of existing, true minor source gasoline dispensing facilities in Indian country. It applies 

only to facilities that dispense greater than 4,000,000 gallons of gasoline in National Ambient Air Quality Standard 

(NAAQS) ozone attainment, unclassifiable or attainment/unclassifiable areas, or dispense greater than 2,100,000 

gallons of gasoline annually in NAAQS ozone nonattainment areas. A gasoline dispensing facility is any stationary 

facility which dispenses gasoline into the fuel tank of a motor vehicle, nonroad vehicle or equipment, including a 

nonroad vehicle or nonroad engine used solely for competition.

This Permit by Rule is not available for use by gasoline dispensing facilities 

within the geographic boundaries of the State of California.

You qualify to submit a Notification of Coverage under the Permit by Rule if you meet all of the 

following criteria:

 You plan to construct a true minor source gasoline dispensing facility that dispenses gasoline for resale or 

non-resale purposes or you plan to modify an existing, true minor source gasoline dispensing facility that 

dispenses gasoline for resale or non-resale purposes;

 Your new or modified true minor source gasoline dispensing facility is located within Indian country;

 Your facility has a potential to emit (PTE) less than the New Source Review (NSR) major source thresholds;

 If located in a serious, severe or extreme ozone nonattainment area, after the proposed construction or 

modification project, your facility is projected to dispense less than 8,000,000 gallons of fuel per year based 

on a 12-month rolling total;

 If located in an attainment, unclassifiable or attainment/unclassifiable ozone area or a marginal/moderate 

nonattainment ozone areas, after the proposed construction or modification project, your facility is 

projected to dispense less than 25,000,000 gallons of fuel per year based on a 12-month rolling total;

 If located in an ozone nonattainment area, after the proposed construction or modification project, your 

facility is projected to dispense more than 2,100,000 gallons of fuel over a consecutive 12 month period;

 If located in an attainment, unclassifiable or attainment/unclassifiable area for ozone, after the proposed 

construction or modification project, your facility is projected to dispense more than 4,000,000 gallons of 

fuel over a consecutive 12 month period;

 You demonstrate, and obtain confirmation from the U.S. Environmental Protection Agency (EPA), that you

have followed the screening process the EPA has provided with respect to the protection of speciesthat are

federally-listed as threatened or endangered under the Endangered Species Act (ESA) or of habitat that is

federally-designated as “critical habitat” under the ESA; and
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 2 of 10

Version 1.0

 You demonstrate, and obtain written confirmation from the EPA, that you followed the screening processto

address any effectsto historic properties eligible for protection under the National Historic Preservation Act

(NHPA).

The reviewing authority retains discretion to terminate your coverage under the Permit by Rule and require a sourcespecific permit even if the above criteria are met. Reasons the reviewing authority may terminate a permitted source’s 

coverage under the Permit by Rule include:

1. The permittee is not in compliance with the provisions of the Permit by Rule; 

2. The reviewing authority determines that the emissions resulting from the construction or modification of the 

permitted source significantly contribute to NAAQS violations, which are not adequately addressed by the 

requirements in the Permit by Rule;

3. The reviewing authority has reason to believe that the permittee obtained coverage under the Permit by Rule by 

fraud or misrepresentation; or

4. The permittee failed to disclose a material fact required by the Notification of Coverage or the regulations 

applicable to the permitted source of which the applicant had or should have had knowledge at the time the 

permittee submitted the Notification of Coverage.

More Information

Information on the definition of a “modification” and “PTE” can be found at 40 CFR 49.152(d) and in the 

“Instructions” document. Additional information on the applicability of the Federal Indian Country Minor NSR Rule

can be found at 40 CFR 49.153.

Information on the ozone attainment status of the area where your facility is located can be found at: 

http://www.epa.gov/airquality/greenbook/. You may also contact your reviewing authority for information on the 

area’s attainment status.

Sources eligible for the Air Quality Permit by Rule for New or Modified True Gasoline Dispensing Facilities may also be 

subject to federal standards under 40 CFR 63 Subpart CCCCCC, National Emission Standards for Gasoline Dispensing 

Facilities, 40 CFR 60 Subpart IIII – Standards of Performance for Stationary Compression Ignition Internal Combustion 

Engines, 40 CFR 60 Subpart JJJJ – Standards of Performance for Stationary Spark Ignition Internal Combustion Engines, 

and 40 CFR 63 Subpart ZZZZ– National Emission Standards for Hazardous Air Pollutants for Stationary Reciprocating 

Internal Combustion Engines. The conditions applicable to sources seeking coverage under this Permit by Rule are 

intended to be generally consistent with the requirements in 40 CFR 63 Subpart CCCCCC, 40 CFR 60 Subpart IIII, 40 CFR 

60 Subpart JJJJ, and 40 CFR 63 Subpart ZZZZ. However, compliance with the applicable requirements in 40 CFR part 63, 

Subpart CCCCCC is required independent of the conditions in the Permit by Rule, and not all requirements applicable 

under Subpart CCCCCC are necessarily included in the Permit by Rule. The Background Document for the Permit by Rule 

identifies the specific requirements in Subparts CCCCCC, IIII, JJJJ, and ZZZZ that are intended to be included in the Permit 

by Rule. The EPA’s brochure for Subpart CCCCCC is available here: http://www.epa.gov/ttn/atw/area/gdfb.pdf. 

Instructions

Step 1: Notify your reviewing authority, including providing appropriate documentation, that you (1) meet one of the

criteria listed in the EPA’s screening process for the protection of any and all species that are federally-listed as

threatened or endangered under the ESA or of habitat that is federally-designated as “critical habitat” under the ESA; 

and (2) satisfy the EPA’s screening process for the NHPA. You must obtain written confirmation from the EPA that the 

threatened and endangered species and historic property screening procedures have been satisfied prior to submitting 

your Notification of Coverage under the Permit by Rule.
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 3 of 10

Version 1.0

Step 2: After receiving notification that you have successfully met the requirements of Step 1, complete all sections of 

the Notification of Coverage under the Permit by Rule (i.e., pages 4 – 10). If you have questions, please contact the 

reviewing authority.

Step 3: Certify that your existing or proposed facility is/will be in compliance with the applicable requirements as stated 

in 40 CFR 49.164 and submit a copy of this notification to the reviewing authority and to the tribe in the area where the 

source is locating. Submittal of this notification form also satisfies the requirement that minor sources in Indian country 

register with the EPA.

After you submit the Notification of Coverage under the Permit by Rule to the reviewing authority:

 You may commence construction of your new source or modification of your existing source under the Permit by 

Rule.

 Your reviewing authority may request additional information from you in order to verify you are eligible for the 

Permit by Rule. 

Applicants are welcome to send comments on the EPA’s need for the information in this application, 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.
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 4 of 10

Version 1.0

Notification of Coverage under the Air Quality Permit by Rule for New or Modified 

True Minor Source Gasoline Dispensing Facilities in Indian Country

Last Modified: March 23, 2015

Version 1.0

Prior to construction or modification, complete this application and submit it to your reviewing authority.

A list of reviewing authorities, their area of coverage, and contact information can be found in Attachment D to the Air 

Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country or visit: 

http://www.epa.gov/air/tribal/tribalnsr.html.

For questions regarding this notification please contact your reviewing authority. 

For instructions on completing this application please see the document “Instructions for Notification of Coverage 

under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian 

Country.”

Section 1: Contact Information

1. Business Name: 2. Date:

3. Site Address: 4. County:

5. Name of Operator at Site (if different from owner): 6. Phone of Operator or Contact at Site (if different from 

owner):

7. Owner: 8. Telephone Number of Owner:

9. Owner’s Mailing Address: 10.Send all correspondence regarding this application to:

Company Name:

c/o:

Address: 

11. Authorized contact regarding this permit application:

Name:

Title:

Phone: 

Email:

FAX:
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 5 of 10

Version 1.0

Section 2: Facility and Technical Information for the Notification of Coverage under the Air 

Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in 

Indian Country

12. This notification is for: 

New retail gasoline dispensing facility (please describe the proposed new source).

_______________________________________________________________________________________________

_______________________________________________________________________________________________

New non-retail gasoline dispensing facility (please describe the proposed new source).

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Modification of an existing gasoline dispensing facility. Please describe the modification below. The definition of 

“modification” can be found at 40 CFR 49.152(d), and in the “Instructions” document available for completing this 

notification form.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

13. North American Industry Classification System/Standard Industrial Classification Code and/or description for the 

facility: 

_______________________________________________________________________________________________

_______________________________________________________________________________________________

14. Will your new or modified facility be located in an ozone nonattainment area? Information on the ozone 

attainment status of the area where your facility is located can be found at: 

http://www.epa.gov/airquality/greenbook/.

Yes No

If you answered ‘Yes,’ specify the classification of the ozone nonattainment area:

Marginal Moderate Serious Severe Extreme

15. Will the PTE of your new facility, or the increase in potential emissions from your modified existing facility, be 

equal to or above the applicable minor NSR thresholds listed below for ANY of the listed pollutants, both in tons 

per year (tpy)? Emissions from your facility may be calculated using the PTE calculator available online at:

http://www.epa.gov/air/tribal/tribalnsr.html. Be sure to include all new or modified emission units at your facility. 

Pollutant Attainment 

Area

Nonattainment Area

Carbon Monoxide (CO) 10 tpy 5 tpy

Particulate Matter (PM) 10 tpy 5 tpy

Particulate Matter 

(PM10) 5 tpy 1 tpy
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 6 of 10

Version 1.0

Pollutant Attainment 

Area

Nonattainment Area

Particulate Matter 

(PM2.5) 3 tpy 0.6 tpy

Sulfur Dioxide (SO2) 10 tpy 5 tpy

Nitrogen Oxides (NOX) 10 tpy 5 tpy

Volatile Organic 

Compounds (VOC) 5 tpy 2 tpy

Yes No

If you answered ‘No’, your source is exempt from the minor NSR program. Please contact your reviewing authority 

to confirm that your facility will not need a permit. If you answered ‘Yes’, continue on to the next question.

16. If located in an attainment, attainment/unclassifiable or unclassifiable area, will the PTE of your facility be 

less than 250 tpy for PM, PM10, PM2.5, VOC, NOX, CO, and SO2? Be sure to include all existing, new, and 

modified emission units at your facility.

Yes No

If you answered ‘No,’ your source does not qualify for the Permit by Rule. Please contact your reviewing 

authority to apply for a site-specific permit. If you answered ‘Yes,’ continue on to the next question.

17. If located in a nonattainment area, will the PTE of your facility for the particular nonattainment pollutant 

be less than the NSR major source thresholds below for ALL pollutants? Be sure to include all existing, 

new, and modified emission units at your facility.

Pollutant Nonattainment Classification NSR Major Source Threshold

Ozone Marginal 100 tpy of VOC or NOX

Moderate 100 tpy of VOC or NOX

Serious 50 tpy of VOC or NOX

Severe 25 tpy of VOC or NOX

Extreme 10 tpy of VOC or NOX

PM10 Moderate 100 tpy

Serious 70 tpy

CO Moderate 100 tpy

Serious 50 tpy

SO2, NO2, PM2.5 No nonattainment classification 100 tpy

Yes No N/A - Not located in any nonattainment area
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 7 of 10

Version 1.0

If you answered ‘No,’ your source does not qualify for the Permit by Rule. Please contact your reviewing 

authority to apply for a site-specific permit. If you answered ‘Yes’ or ‘N/A,’ continue on to the next question.

18. Do you agree to comply with all requirements of the Permit by Rule as stated in CFR 49.164?

Yes No

If you answered ‘No,’ your source does not qualify for the Permit by Rule under 40 CFR 49.164 and you must 

obtain a site-specific permit from your reviewing authority.

19. Emission Units

Information regarding the existing and planned emission units at your facility is required by 40 CFR 49.154 

and 49.160. Please provide the information in the following table for each emission unit at the site that is 

or will be owned, leased or operated by the applicant. Examples of potential emission units include 

gasoline storage tanks, gasoline pumps and emergency engines. 

For each emissions unit, include supporting documentation for the PTE of each unit with your notification 

of coverage. In addition, for existing emission units, include the most recent actual annual emissions. See 

40 CFR 49.154(a)(2). (For more information on how to calculate actual emissions, go to: 

http://www.epa.gov/air/tribal/tribalnsrcalculators.html.) As needed, please include any other relevant 

information with your notification.
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 8 of 10

Version 1.0

List of Existing and Planned Emission Units (attach additional copies of this table as necessary):

Unit ID#

Description of Equipment and/or Process 

(include any input materials or fuels)

Maximum Capacity or 

Production Rate

Description of Pollution 

Control Equipment

Operating 

Schedule

Existing, New or 

Modified 

(include 

installation date

for existing)
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 9 of 10

Version 1.0

Section 3: Information on Completing Screening Processes that Have Been Satisfied Prior to 

Submitting a Notification of Coverage under the Air Quality Permit by Rule for New or Modified 

True Minor Source Gasoline Dispensing Facilities in Indian Country

20. Threatened or Endangered Species 

Have you obtained confirmation from the EPA that you have satisfactorily completed the screening process 

for the protection of species that are federally-listed as threatened or endangered under the ESA or of 

habitat that is federally-designated as “critical habitat” under the ESA? If you answer ‘No,’ you cannot gain

coverage under this Permit by Rule.

Yes No

21. Historic Properties

Have you obtained confirmation from the EPA that you have satisfactorily completed the screening process

to determine if the construction, modification or operation of your new or modified true minor source of air 

pollutants has the potential to cause effectsto historic properties (pursuant to the NHPA)? If you answer

‘No,’ you cannot gain coverage under this Permit by Rule.

Yes No

Section 4: Additional Information about this Air Quality Permit by Rule for New or Modified True 

Minor Source Gasoline Dispensing Facilities in Indian Country

This section provides information on the sizes of sources in terms of emissions that are eligible for the Permit by Rule. 

The emission limitations and standards in this Permit by Rule are generally expected to ensure that source-wide 

emissions are below the rates shown in the following table:

Pollutant of 

Concern

Serious, Severe or Extreme 

Ozone Nonattainment Areas

Ozone Attainment, Unclassifiable or 

Attainment/Unclassifiable Areas and 

Moderate or Marginal Ozone 

Nonattainment Areas

VOC 7.5 tpy 25 tpy
EPA Form No. 5900-343

EPA ICR No. 1230.27

OMB Control No. 2060-0003

Approval expires 4/30/2017

Notification of Coverage: Gasoline Dispensing Facilities Page 10 of 10

Version 1.0

Applicant’s Statement (to be signed by the applicant)

I certify that this document and all attachments were prepared under my direction or supervision according to a 

system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on 

my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the 

information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.

Name: _____________________________Name: ____________________________Date:__________

(Signature) (Print or Type)

Title: _____________________________________