EPA Form No. XXXX

- XXX
EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

United States Environmental Protection Agency Program
Address
Phone

Fax
Web address Reviewing Authority Program
Address
Phone

Fax
Web address



## FEDERAL IMPLEMENTATION PLAN FOR MANAGING AIR EMISSIONS FROM TRUE

MINOR SOURCES ENGAGED IN OIL AND NATURAL GAS P RODUCTION IN INDIAN

COUNTRY

Registration for N ew True Minor Oil and Natural Gas Sources and Minor Modifications at Existing True Minor Oil and Natural Gas Sources

Please submit information to:



### [Reviewing Authority
Address Phone]

A. GENERAL S OURCE INFORMATION (See Instructions Below)
1. Company Name 2. Source Name

3. Type of Oil and Natural Gas Operation 4. New True Minor Source?  Yes  No

5. True Minor Source Modification?  Yes  No

6 . NAICS Code 7 . SIC Code

8

. U.S. Well ID(s) or API Number(s) [if applicable]

9 . Reservation 1 0 . County 1 1 a. Latitude 1 1 b. Longitude

[ Disclaimer ] The public reporting and recordkeeping burden for this collection of information is estimated to average 6 hours per response. 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 Strateg ies 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. XXXX

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EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

Page 2 of 7 

### B. CONTACT INFORMATION (See Instructio ns Below)

1. Owner Name Title

Mailing Address

Email Address

Telep hone Number Facsimile Number

2. Operator Name (if different from owner) Title

Mailing Address

Email Address

Telephone Number Facsimile Number

3. Source Contact Title

Mailing Add ress

Email Address

Telephone Number Facsimile Number

4. Compliance Contact Title

Mailing Address

Email Address

Telephone Number Facsimile NumberEPA Form No. XXXX

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EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

Page 3 of 7 Include all of the following information 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 poll ution 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. Indicate all requirements referenced in the Oil and Natural Gas FIP that apply/will apply to emissions units and air pollution generating activities at the

source o r proposed. Include statements indicating each emissions unit that is an emissions unit potentially subject to the requirements referenced in the FIP, but does not meet the definition of an affected facility under the referenced requirement, and therefore , is not subject to those requirements.

 For each emissions unit comprising the new source or modification

, estimates of the t otal allowable (potential to emit if there are no legally and practically enforceable restrictions) 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, fluorides (gaseous and particulate), sulfuric ac id mist (H 2 SO 4 ), hydrogen sulfide (H 2 S), total reduced sulfur (TRS) and reduced sulfur compounds, including all calculations for the estimates.

 For each emissions unit comprising the new source or modification

, e stimates of the total actual emissions
fr om 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 compound (VOC), lead (Pb) and lead compounds, ammonia (NH 3 ), fluorides (gaseou s 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.

 OtherEPA Form No. XXXX

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EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

Page 4 of 7 

### D. TABLE OF ESTIMATED EMISSIONS

Provide in the table below e stimat es of the total actual and allowable (potential) emissions in tons

per year (tpy) for the following pollutants for all emissions units comprising the new source or
modification

.

POLLUTANT TOTAL ACTUAL EMISSIO NS (TPY) TOTAL ALLOWABLE OR P OTENTIAL EMISSION S (TPY)

PM

PM 10

PM 2.5

SO x

NO x

CO

VOC

Pb

NH 3

Fluorides

H 2 SO 4

H 2 S

TRSEPA Form No. XXXX

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EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

Page 5 of 7 Instructions

Please answer all questions. If the item does not apply to the source and its operations write “n/a”. If the
answer is not kno wn write "unknown".

A . General Source Information

1. Company Name : Provide the complete company name

. For corporations, include divisions or subsidiary name, if any.

2. Source Name : Provide the source name. Please note that a source is a site, place

, or lo cation that may contain one or more air pollution emitting units.

3. Type of Operation : Indicate the generally accepted name for the production segment operation (e. g. , oil and gas well site, tank battery, compressor station )

.

4. New True Minor Source : [Per In dian Country Minor N ew Source R eview Rule , 40 CFR 49.153 ]

.

5. True Minor Source Modification : [ Per Indian Country Minor New Source Review Rule, 40 CFR 49.153 ]

.

6. NAICS ( North American Industry Classification System ) : The NAICS Code for your oil and natural ga s source can be found at the following link for North American Industry Classification System : http://www.census.gov/eos/www/naics/

.

7. SIC Code ( Standard Industrial Classification Code ) : Although the new North American Industry Classification System (NAICS) has replaced the SIC codes, much of the Clean Air Act permitting processes
continue to use these codes. The S IC Code for your oil and natural gas source can be found at the following link for Standard Industrial Classification Code s: http://www.osha.gov/pls/imis/ sic_manual.html

.

8. U.S. Well ID or API Number : Provide the ID(s) for all oil and natural gas production wells associated with the facility, if applicable. Unique well identifier as assigned by the Federal or State oil and gas regulatory agency with primacy , using the American Petroleum Institute (API) Standard for number format (pre

- 2014)
or th e Professional Petroleum Data Management (PPDM) Association US Well Number Standard (2014

- present)

. Provide IDs for all oil and natural gas production wells associat ed with the facility, if applicable. May not be applicable for downstream production sources, such as compressor stations.

9. Reservation : Provide the name of the Indian reservation with in which the source is operating.

10. County : Provide the County with in wh ich the source is operating.

11. Latitude & Longitude (11a . and 11b.) : Provide latitude and longitude location(s) in decimal degrees, indicating the datum used in parentheses. These are GPS (global positioning system) coordinates. This information should
be provided in decimal degrees with 6 digits to the right of the decimal point, indicating the datum used in parentheses (i.e., NAD 27, NAD 83, WGS 84

– WGS 84 is preferred over NAD 27)

.EPA Form No. XXXX

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EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

Page 6 of 7 B. Contact Information

Please provide the information requested i n full.

1. Owners : L ist 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 aut horized to receive requests for data and
information.

4. Compliance C ontact : The compliance contact must be the local 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 attachments will enable EPA to understand the type of oil and natural gas production source being registered and the nature and extent of the air pollutants to be
emitted.

D. Emissions

1. Actual Emissions : Estimates of actual emissions must take into account equipment, operating conditions, and air pollution control measures. For a n emissions unit 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 types of materials processed, stored, or combusted during the preceding calen dar year. However, if you believe that the actual emissions in the preceding calendar year are not representative of the emissions that your unit will actually emit in coming years, you may submit an estimate of projected actual emissions along with the ac tual emissions from the preceding calendar year and the rationale for the projected actual emissions. For a unit that has not operated for an entire year, the actual emissions are the estimated annual emissions for the current calendar year.

2. Allowable Em issions (See also, Potential to Emit) : Emissions rate of a n emissions unit calculated using the maximum rated capacity of the unit (unless the source is subject to practically and legally enforceable limits which restrict the operating rate, or hours of op eration, or both) and the most stringent of the following:

 Any applicable standards as set forth in 40 CFR parts 60 , 61 and 6 3 ;

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

 An y emissions rate specified as a federally enforceable permit condition, including those with a future compliance date.EPA Form No. XXXX

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EPA ICR No. 1230.27
OMB Control No. 2060

- 0003 Approval expires 4/30/2017

Page 7 of 7 3. Potential to Emit : The maximum capacity of a n emissions unit to emit a pollutant under its physical and operational design. Any physica l or operational limitation on the capacity of the unit to emit a pollutant, including air pollution control equipment 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 the limitation or the effect it would have on emissions is enforceable as a practical matter. See Allowable Emissions.

4. The emission estimates can be based upon actual test data or, in the absence of such data, upon procedures acceptab le to the Reviewing Authority . The following procedures are generally acceptable for estimating emissions from air pollution sources:

 Unit

- specific emission tests;

 Mass balance calculations;

 Published, verifiable emission factors tha t are applicable to the u nit (i.e

., manufacturer specifications);

 Other engineering calculations; or

 Other procedures to estimate emissions specifically approv ed by the Reviewing Authorit y

.

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

.