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 

## Notificatio n of Coverage u nder the Air Quality Permit by Rule for New or Modified

True Minor Source Gasoline Dispensing Facilities in Indian Country

Last Modified: March 2 3 , 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 t he modification of existing, true minor source gasoline dispensing facilities in Indian c ountry . It applies

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

(NAAQS) ozone attainment , uncla ssifiable 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, non road 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 Calif ornia.

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 h as 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 dispens e 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 modif ication 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 pr ojected 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 ;

 Y o u de m o n s t r a t e , and obtain confirmation from the U.S. Environmental Protection Agency (EPA)

, t h a t yo u

have followed the screening process the E PA has provided w i t h re s p e c t t o t h e p r o t e c t i o n o f s p e ci es t ha t a re

feder all y

- li s t ed a s threatened or e n d an gered u n der t h e E n d an gered S p e ci es A c t (ESA) o r o f habi t a t t ha t i s

feder all y

- de s i g na t ed a s “c r i t ic a l hab i t a t ” u n der t h e E S A; andEPA 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  Y o u de m o n s t r a t e, and obtain written confirmation from the EPA, that y o u f o ll o wed t h e s c ree nin g p r o c ess t o

address any effe c t s t o hi s t o r i c p r o p er t i e s eligible for protection under the National Historic Preservation Act

(NHPA)

.

The reviewing authority retains discretion to terminate your coverage under the P ermit by R ule and require a source

specific permit even if the above criteria are met. Reasons t he reviewing authority may terminate a permitted source’s

coverage under the P ermit by R ule include :

1. The permittee is not in compliance with the provisions of the P ermit by R ule ;

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 add ressed by the

requirements in the P ermit by R ule;

3. The reviewing authority has reason to believe that the permittee obtained c overage under the P ermit by R ule 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.

Mo re 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 th e 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 Standa rds for Gasoline Dispensing

Facilities

, 40 CFR 60 Subpart IIII

– Standards of Performance for Stationary Compression Ignitio n Internal Combustion

Engines, 40 CFR 60 Subpart JJJJ

– Standards of Performance for Stationary Spark Ignition Internal Combustion E ngines

, 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 genera lly 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 Subpart s CCCCCC, IIII, JJJ J, 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

, t h a t yo u (1) meet o n e o f t h e

c r i t er i a l i s t ed i n the EPA’s screening process for t h e p r o t e c t i o n o f an y an d al l s p e ci es t ha t a re feder all y

- li s t ed a s

threatened or e n d an gered u n der t h e ESA o r o f habi t a t t ha t i s feder all y

- de s i g na t ed a s “c r i t ic a l hab i t a t ” u n der t h e E S A;

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, c omplete 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. 16 4 and s ubmit a copy of this notification to the reviewing authority and to the tribe in the area where the

source is locating

. Submittal of th is 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 r eviewing a uthority :

 You may commence construction of your new source or modification of your existing source under th e 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 s end comments on the EPA’s need for th e 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 2 3 , 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 f or Notification of Coverage

under the Air Quality Permit by Rule f or New o r 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. A uthorized 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 gas oline dispensing facility (please describe the proposed new source ).

_______________________________________________________________________________________________

___________________________________________________________ ____________________________________

New n on

- retail gas oline dispensing facility (please describe the proposed new source)

.

_______________________________________________________________________________________________

_____________

______________________________________________ ____________________________________

Modification of an existing gasoline dispensing facility. Please describe the modification be low. T he 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 a n ozone no nattainment 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

1 5

. 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 pollutant s , 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 un its at your facility

.

Pollutant Attainment

Area Nonattainment Area

Carbon Monoxide (CO) 10 tpy 5 tpy

Particulate Matter (PM) 10 tpy 5 tpy

Particulate Matter

(PM 10 ) 5 tpy 1 tpyEPA 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

(PM 2.5 ) 3 tpy 0.6 tpy

Sulfur Dioxide (SO 2 ) 10 tpy 5 tpy

Nitrogen Oxides (NO X ) 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, PM 10 , PM 2.5 , VOC, NO X , CO, and SO 2 ? 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 les s 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 NO X

Moderate 100 tpy of VOC or NO X

Serious 50 tpy of VOC or NO X

Severe 25 tpy of VOC or NO X

Extreme 10 tpy of VOC or NO X

PM 10 Moderate 100 tpy

Serious 70 tpy

CO Moderate 100 tpy

Serious 50 tpy

SO 2 , NO 2 , PM 2.5 No nonattainment classification 100 tpy

Yes No N/A

- Not located in any nona ttainment areaEPA 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. 16 4 ?

Yes No

If you answered ‘No

, ’ your source does not qualify for the Permit by Rule under 40 CFR 49. 16 4 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.e pa.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

i nstallation date

f or 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 y o u obtained confirmation from the EPA t h a t yo u have satisfactorily completed the screening process

for t h e p r o t e c t i o n o f s p e ci es t ha t a re feder all y

- li s t ed a s threatened or e n d an gered u n der t h e E S A o r o f

habi t a t t ha t i s feder all y

- de s i g na t ed a s “c r i t ic a l hab i t a t ” u n der t h e E S A? If you answer ‘No

, ’ you cannot gain

coverage under this Permit by Rule

.

Yes No

21

. Historic Properties

Have y o u obtained confirmation from the EPA that you have satisfactorily completed t h e s c ree nin g p r o c ess

t o de t e r m in e i f the construction, modification or operation of your new or modified true minor source of air

pollutants ha s t h e p o t e n t ia l t o ca u se effe c t s t o hi s t o r i c p r o p er t i e s (pursuant to the NHPA) ? If you answer

‘No

, ’ you cannot gain coverage under this Permit by Rule

.

Yes No



### Section 4: Additional Information a bout t his 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 P ermit by R ule are generally expected to ensure that source

- wide

emissions are below the rates shown in the following table:

Pollutant of

Concern Serious, Severe or E xtreme

Ozone Nonattainment Areas Ozone Attainment , Unclassifiable or

Attainment/Unclassifiable Areas and

Moderate or Marginal Ozone

Nonattainment Areas

VOC 7 .5 tpy 25 tpyEPA 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 sub mitted is, to the best of my knowledge and belief, true, accurate, and complete.



### Name: _____________________________Name: ____________________________Date:__________

(Signature) (Print or Type)



### Title: _____________________________________