EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 1 of 23 

## United States Environmental Protection Agency

**Pacific Southwest**

**– Region 9** 

**Clean Air Act Permit** 

**Federal Indian Country Minor New Source Review Program**

http://www.epa.gov/ caa

- permitting/tribal

- nsr

- permits

- region

- 9



## Request for Coverage under the **General Air Quality Permit for New or**

**Modified Minor Source Gasoline Dispensing**  **Facilities in Indian Country**

**with in California** 

Last Modified: September 2 9 , 2016

Version 1.0

This Request for Coverage under the General Air Quality Permit for New or Modified Minor Source Gasoline Dispensing

Facilities in Indian Country within California ( the General Permit) is available for the construction or modification of certain

minor sou rce gasoline dispensing facilities in Indian country , within the geographical boundaries of California

. Specifically,

the General Permit is potentially av ailable for such facilities within the geographic boundaries of California that are located

in an Indian reservation or in another area of Indian country (as defined in 18 U.S.C. 1151) over which an Indian tribe, or

the EPA, has demonstrated that the tribe has jurisdiction

, and where there is no EPA

- approved program in place

. A

gasoline dispensing facilit y (GDF) is any stationary source which dispenses gasoline into the fuel tank of a motor

vehicle, motor vehicle engine, nonroad vehicle, or nonroad engine, including a nonroad vehicle or nonroad engine

used solely for competition e .g. , a retail gas station)

.

A n owner or operator of a source that meets the eligibility criteria may seek coverage under the General Permit by

submit ting this Request for Coverage when the General Permit becomes effective. You may contact your reviewing

authority or check the following website to determi ne whether the General Permit is effective: https://www.epa.gov/caa

permitting/california

- tribal

- gasoline

- permits

.

Questionnaire: For assistance with determin ing whether the proposed new or modified GDF source may be eligible for

the General Permit and the owner or operator should submit this Request for Coverage, the owner or operator may

refer to the “Questionnaire under the General Air Quality Permit for New or Modified Minor Source Gasoline Dispensing

Facilities in Indian Country within California ” (Questionnaire)

.

Instructions: For assistance with completing the Request for Coverage, the owner or operator should refer to the

“Instructions for Request for Coverage under the General Air Quality Permit for New or Modified Minor Source

Gasoline Dispensing Facilities in Indian Country within California ” (Instructions), which provide additional detail on the

requested information. Informati on on the definition of a “modification” and “potential to emit” or “PTE” can be found

at CFR 49.152(d) and in the Instructions

The Questionnaire and Instructions are available on the EPA Region 9 website here: https://www.epa.gov/caa

permitting/california

- tribal

- gasoline

- permits

.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 2 of 23 Eligibility Criteria

The owner or operator must meet the following criteria to potentially qualify for coverage under the General Permit and

to submit a Request for Coverage:

• You , the owner/operator, plan to construct a new or modified minor source , as defined in 40 CFR 49.152(d)

, that

is, or includes, a GDF, and your source has a potential to emit (PTE) less than the Prevention of Significant

Deterioration and New Source Review (NSR) major source thresholds. For purposes of this eligibility c riterion , you r

PTE calculation must include the PTE of all existing, new and modified emiss ion units at your source , including

those that are not part of the GDF.

• Your new or modified minor source gasoline dispensing facility is located within the geographic boundaries of

California , and located in an Indian reservation or in another area of Ind ian country (as defined in 18 U.S.C. 1151)

over which an Indian tribe, or the EPA, has demonstrated that the tribe has jurisdiction

, and where there is no

EPA

- approved program in place

.

• The new or modified GDF i s not, or will not, be located at a major sou rce of hazard ous air pollutants.

• I f the source is located in a n area that has been designated as serious, severe or extreme nonattainment for the

federal ozone standard , after the proposed construction or modification project, the source (including existing

equipment as well as new and modified equipment) will dispense less than 15,000,000 gallons of fuel per year

based on a 12

- month rolling total . I f the source is located in an area that is attainment, unclassifiable or

attainment/unclass ifiable or marginal/moderate nonattainment for the federal ozone standard , after the

proposed construction or modification project, the source (including existing equipment as well as new and

modified equipment) will dispense less than 25, 000,000 gallons o f fuel per year ba sed on a 12

- month rolling total.

• The proposed new or modified GDF will use a Stage I dual

- point vapor balance system.

• If t he proposed new or modified GDF is

, or will be

, located in a federal ozone nonattainment area , it will be

equipped with a CARB Phase II Enhanced Vapor Recovery (EVR) System and In

- Station Diagnostic (ISD) system

, using CARB certified equipment.

• Any new or modified emergency engines at the source are exempt under 40 CFR 49.153(c).

• The owner or operator demonstrate s that the source meet s one of the criteria listed in Appendix A with respect

to the protection of any and all species that 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

• The owner or operator has completed the screening process in Appendix B to determine if the construction,

modification or operation of your new or modified minor source of air pollutants has the potential to cause effects

to historic properties

.

• You can otherwise comply with the terms and conditions of the General Permit.

In addition, t h e General Permit is not available to:

• Sources that store or transfer aviation gasoline at airports or other similar sour ces that dispense fuel through

mobile (portable) fueling equipment.

• A proposed or modified GDF located in an ozone nonattainment area that includes any aboveground storage tank s

( A ST s ) as part of the new or modified source

.

Reviewing Authority Discretion to Terminate General Permit Coverage

Applicants should note that t he reviewing authority retains discretion to t erminate a source’s coverage under this General

Permit and require a source

- specific permit even if the above criteria are met. Reasons the reviewing authority m a y

terminate a permitted source’ s coverage under this General Permit include:EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 3 of 23 1. The permittee is not in compliance with the provisions of the General Permit;

2. The reviewing authority has reasonable cause to believe that the permittee obtained Approval of the Request for

Coverage by fraud or misrepresentation; or

3. The permittee has failed to disclose a material fact required by the Request f or 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 Request for Coverage.

More Information

Information on the ozone attainment status of the area where your source 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 General Permit may also be subject to federal standards under 40 CFR 63 Subpart CCCCCC,

National Emission Standards for Gasoline Dispensing Facilities . The conditions applicable to sources seeking coverage

under this General Permit are int ended to be generally consistent with the requireme nts in 40 CFR 63 Subpart CCCCCC ;

h owever, compliance with the applicable requirements in 40 CFR part 63, Subpart CCCCCC is required independent of

the conditions in the General Permit, and not all requirements applicable under Subpart CCCCCC are necessarily

included in the General Permit. The Technical Support Document for this General Permit identifies the specific

r equirements in Subpart CCCCCC that are included in the General Permit. The EPA’s brochure for Subpart CCCCCC is

available here: http://www.epa.gov//ttn/atw/area/gdfb.pdf

.

Steps to obtain coverage:

Step 1: Accurately c omplete all sections of the Request for Coverage application. If you have any questions, please

contact the reviewing authority at:

Mailing Address: U.S. EPA Region 9, Pacific Southwest

Air Permits Office Chief, Air

- 3

75 Hawthorne Street

San Francisco, CA 94105

Phone: 415

- 972

- 3974

Email: R9AirPermits@epa.gov

Step 2: S ubmit a copy of this Request for Coverage to the reviewing authority at the above address and to the Indian

governing body , such as the tribal chairperson, in the area where the source is locating. Submittal of this form also

satisfies the requirement that minor sources in Ind ian country register with the EPA at 40 CFR 49.160(c ) (1)(iii)

.

After you submit the Request for Coverage under the General Permit to the reviewing authority:

• You may not commence construction of your new source or modification of your existing source until you

receive notification of the final decision on your application for coverage under this General Permit.

• Your reviewing authority will process your Request for Coverage according to the procedures outlined in 40 CFR

49.156(e)

.

• T he reviewing author ity must act on your request for coverage under the G eneral P ermit as expeditiously as

possible, but it must notify you of the final decision within 90 days of its receipt of your coverage request.

• I f the reviewing authority determines that your request fo r coverage under the G eneral P ermit includes all the

relevant information and is complete, it will notify you in writing as soon as that determination is made within

the 45 days

.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 4 of 23 • Within 30 days from receipt of your application, i f the application is not complete and more information is

needed, your reviewing authority must notify you. You must submit such information within 15 days of the

request. If you do not receive a request for additional information or a notice that your r equest for coverage

under a general permit is complete within the 45

- day completeness review period, your request will be deemed

complete.

• If the reviewing authority sends a letter to you approving your request for coverage under the General Permit

,

you m ust comply with a ll conditions and terms of the General P ermit. You will be subject to enforcement action

for failure to obtain a preconstruction permit if you construct the emissions unit(s) or source with reviewing

authority approval and your source is l ater determined not to qualify for the conditions and terms of the general

permit.

• If the reviewing authority approves your Request for Coverage under th e General Permit, you must post,

prominently, a copy of the letter granting such request at the site wh ere your source is locating.

• Your permit becomes invalid if you do not commence construction within 18 months after the effective date of

your request for coverage under a general permit, if you discontinue construction for a period of 18 months or

more

, o r if you do not complete construction within a reasonable time. The reviewing authority may extend the

18

- month period upon a satisfactory showing that an extension is justified.

• Any source eligible to request coverage under a general permit may, instead, request a source

- specific permit by

applying for a permit under 40 CFR 49.154.

Applicants are welcome to send comments on the U.S. Environmental Protection Agency ’s need for the information in this Request

for Coverage , and any suggestion 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, Washingt on, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed Request for

Coverage to this address

.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage: General Permit for Gasoline Dispensing Facilities

In Indian Country within California 

## Request for Coverage under the **General Air Quality Permit for**

**New or Modified Minor Source Gasoline Dispensing Facilities in** 

**Indian Country within California**

http://www.epa.gov/ caa

- permitting/tribal

- nsr

- permits

- region

- 9

Pr ior to construction or modification, complete the information below and submit it to the reviewing authority at the

address above

. You may not commence construction or modification until you receive notification of the final

decision on your Request for C o verage under the General Permit from the reviewing authority.



### Section 1: Contact Information

1. Business Name: 2. Source Name :

3. Physical Site Address: 4. Reservation or other Area of Indian Country:

5. Owner: 6. Telephone Number and Email Address of Owner:

7. Mailing Address for Owner: 8. Name of Operator or Contact at Site (if different from

owner):

9. Telephone Number and Email address of Operator or

Contact at Site (if different from owner): 10. C orrespondence Address :

11. Contact Information for this Request for Coverage :

Name:

Title: Email:

Telephone:EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 6 of 23 

### Se ction 2: Source Information

12. Source Description . S elect one and describe:

( Example description : This source will be a 24

- hour convenience store with an estimated 25 ,000 gallons per month in

gasoline sales. We plan to install eight (8) dispenser islands and four (4) 25,000

- gallon capacity underground storage

tanks equipped with Phase II EVR Systems with ISD s

. )

(P lease describe the proposed new source).



## □ New gasoline dispensing facility



## □ Modification of an existing source that is, or includes, a gasoline dispensing facility

___________________________________

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

source :

 4471 NAICS (Gasoline Stations)

 44711 NAICS (Gasoline Stations without Convenience Stores)

 447110 NAICS (Convenience St ations with Convenience Stores)

 44719 NAICS (Other Gasoline Stations)

 447190 NAICS (Other Gasoline Stations)

 5411 SIC (Grocery Stores)

 5541 SIC (Gasoline Service Stations)

 Other

– please specify _____NAICS; _____SIC

14. Will your new or modified GDF be located in a nonattainment area for the National Ambient Air Quality Standards

(NAAQS) for ozone ? Information on the ozone attainment status of the area where your source is located can be

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

.



## □ Yes 

## □ No

If you r answer is ‘Yes’, specify the classification of the ozone nonattainment area:



## □ Marginal 

## □ Moderate 

## □ Serious 

## □ Severe 

## □ ExtremeEPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 7 of 23 15. Will the potential to emit ( PTE ) of your new source , or the increase in potential emissions from your modified existing

sou rce , be equal to or above the applicable minor NSR thresholds listed below for ANY of the listed pollutants

, in tons

per year (tpy)? Emissions from the gasoline dispensing equipment at your source may be calculated using the PTE

calculator available online at: https://www.epa.gov/caa

- permitting/california

- tribal

- gasoline

- permits . Be sure to

include all new or modified emission units at your source, including those not a part of the GDF

. Information on the

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

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

.



## □ Yes 

## □ No

Pollutant Attainment Area a Nonattainment Area

CO 10 tpy 5 tpy

PM 10 tpy 5 tpy

PM 10 5 tpy 1 tpy

PM 2.5 3 tpy 0.6 tpy

SO 2 10 tpy 5 tpy

NO X b 10 tpy 5 tpy

VOC b 5 tpy 2 tpy

Lead 0.1 tpy 0.1 tpy

Fluorides 1 tpy NA

Sulfuric Acid Mist 2 tpy NA

H 2 S 2 tpy NA

Total Reduced sulfur 2 tpy NA

Reduced sulfur

compounds 2 tpy NA

a I f part of a Tribe’s area of Indian country is designated as attainment and another

part as nonattainment, the applicable threshold for a proposed source or

modification is determined based on the designation where the source would be

located. If the source straddles the two areas, the more stringent thresholds apply.

b In extreme ozone nonattainment areas, section 182(e)(2) of the Act requires any

change at a major source that results in any increase in emissions to be subject to

major NSR permitting. In ot her words, any changes to existing major sources in

extreme ozone nonattainment areas are subject to a “0” tpy threshold, but that

threshold does not apply to minor sources.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 8 of 23 If you answered ‘ No ’, your proposed new source or modification is exempted from p ermit requirements under the

Federal Indian Country M inor NSR program. Please contact the reviewing authority to confirm that your source will

not need a permit. If you answered ‘ Yes ’, continue on to the next question.

16. Will the PTE of your source be less than 250 tpy for all regulated NSR pollutants including , but not limited to

, lead,

PM 10 , PM 2.5 , VOC, NO

x , CO, and SO 2 ? For this calculation, b e sure to include all existing , new and modified emission

units at your source, including emission units t hat are not part of the GDF

.



## □ Yes 

## □ No

If you answered ‘ No ’, your source does not qualify for the General Permit. Please contact the reviewing authority to

apply for a site

- specific permit. If you answered ‘ Yes ’, continue on to the next question.

17. If y our source is located in a nonattainment area for any NAAQS pollutant , will the PTE of your source for all such

nonattainment pollutant s be less than the applicable NSR major source thresholds below? For this calculation, b e sure

to include all existing, n ew, and modified emission units at your source , including any emission units that are not part

of the GDF

.

Pollutant Attainment Area Nonattainment Area

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

PM 10

, PM 2.5 Moderate 100 tpy of PM 10 or PM 2.5

Serious 70 tpy

CO Moderate 100 tpy

Serious 50 tpy

SO 2 , NO 2 No Nonattainment

Classification 100 tpy



## □ Yes 

## □ No 

## □ N/A

– Not located in any nonattainment area s

If you answered ‘ No ’, your source does not qualify for the General Permit. Please contact your reviewing authority to

apply for a site

- specific permit. If you answered ‘ Ye s’ or ‘ N/A ’, continue on to the next question.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 9 of 23 18. Do the owner and operator of your source agree to comply with all requirements of the General Permit?



## □ Yes 

## □ No

If you answered ‘ No ’, your source does not qualify for the General Permit and you must obtain a source

- specific permit

from your reviewing authority.



### Section 3: Technical Information Concerning Emission Units at the Source

As needed , additional pages may be provided by the applicant and added to the Request for Coverage

. Please u se a unique

ID# for each piece of equipment.

19. Emissi on Units

Information regarding the existing and p roposed new or modified emission units at your source is required by 40 CFR

49.154 and 49.160. Please provide all of the requested information in the following table for each such emission unit

at the s ource that is or will be owned, leased or operated by the owner or operator of the source . Examples of potential

emission units include gasoline storage tanks, gasoline pumps and emergency engines.

• For each emission unit, include supporting documentation for the PTE of each unit with your request for

coverage. In addition, for existing emission units, include the most recent actual annual emissions. See 40 CFR

49.154(a)(2).

• The table includes inform ation requesting whether the pa rticular emission unit is “CARB certified.” Not all

equipment at your GDF is required to be CARB certified. As such, this information only affects your eligibility

to seek coverage under the General Permit for that equipme nt which is required to be installed and CARB

certified ( such as Phase II E VR and ISD Systems).

• For sources installing Phase II EVR and ISD systems, please include all CARB certified equipment that will be

installed.

• For emergency engines, please include the model year and purpose (such as, power backup or fire pump).

• For storage tanks, please include whether they are aboveground or underground . See the Eligibility Criteria

section of the Request for Coverage regarding aboveground storage tanks.

• Please review the eligibility criteria at the beginning of the Request for Coverage to ensure the information

provided demonstrates you are eligible for the General Permit.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 10 of 23 

### L i st of Existing, New, and Modified Emission s Units ( applicants should attach additional copies of this table as necessary to list all emission units

at the source ):

Unit ID# De scription of Equipment and/or Process

(including any input materials or fuels) Maximum

Capacity or

Production Rate Description of Pollution

Control Equipment Existing, New or Modified

(include installation date

for existing and most recent

actual annual emissions ) Yes or No: CARB

Certified Equipment

(include applicable

Executive Order, if

CARB Certified)

Sample Underground Storage Tank for Reformulated

Gasoline 50,000 gallons Stage I

– Dual point vapor

balance system New Yes, VR

- 201

- UEPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 11 of 23 

### Section 4: Information for Completing Screening Processes that Must Be Satisfied to Request Coverage

under the General Permit

20. Threatened or Endangered Species

Have you demonstrated that you meet one of the criteria listed in Appendix A with respect to the protection of any

and all species that are federally listed as threatened or endangered under the federal E ndangered Species Act (E SA )

and habitat that is federally designated as “critical habitat” under the ESA? If you answered ‘No,’ you cannot request

coverage under this General P ermit.



## □ Yes 

## □ No

If you answered ‘Yes,’ then you must provide the appropriate documentation as specified in Appendix A to support

this demonstration to the EPA to qualify for coverage under this General P ermit. Please indicate under which of the

following criteria in Appendix A you are using in order to satisfy this requirement:



## □ A 

## □ B 

## □ C 

## □ D 

## □ E

As provided in Appendix A, the EPA must provide confirmation that you satisfactorily completed th is screening

procedure and meet o n e o f t h e e li g i bi l i t y c r i t er i a li s t e d in Appendix A in order for you to be eligible for coverage under

the General Permit.

21. Historic Properties

Have you completed the screening process in Appendix B to determine if the construction, modification or operation

of your new or modified minor source of air pollutants has the potential to cause effects to historic properties? If you

answered ‘No,’ you c annot request coverage under this General P ermit.



## □ Yes 

## □ No

If you answered ‘Yes,’ then you must provide the appropriate documentation concerning your completion of th is

screening process as specified in Appendix B to the EPA to qualify for coverage und er this General P ermit.

As provided in Appendix B, the EPA must provide confirmation that y o u ha ve satisfactorily c o m pl e t ed t hi s s c ree nin g

p r o c e s s in order for you to be eligible for coverage under the General Permit.



### Section 5: Additional Information

This section provides information on the sizes of sources in terms of potential emission s that are potentially eligible for

coverage under the General Permit. The emission limitations and standards in this General Permit are generally expected

to ensure th at emissions from a GDF qualifying for coverage are below the rates shown in the following table . The PTE of

any individual source , however, may vary.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 12 of 23 Pollutant of Concern Serious, Severe or

Extreme Ozone

Nonattainment Areas Ozone Attainment, Unclassi fied or

Attainment/Unclassifiable Areas and

Moderate or Marginal Ozone

Nonattainment Areas

VOC 10 tpy 30 tpy



## 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 th e

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

Name:

___________________________________ __ Title : _____________________________________________

(Print or Type)

Name: ____________________________

________________________________________ (Signature)

Date: _____________________________________________________________________EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 13 of 23 

## A **pp e**  **n d**  **i x**  **A**

**– Threatened or**  **E n**  **da n**  **g e**  **r ed**  **S p**  **ec i**  **es R**  **e q**  **ui r**  **e m**  **en t**  **s**

T h e p u r p os e o f t hi s appendix i s t o a s s i s t y o u i n completing t h e screening procedure for addressing threatened or

endangered species when submitting your Request for Coverage under the General Air Quality Permit for New or

Modified Minor Source Gasoline Dispensing Facilities in Indian Country within California (General Permit)

. I n o rder t o

b e e l i g ibl e f o r c o ver a ge u n d e r the General Permit

, y o u must de m o n s t r a t e t h a t yo u qualify under o n e o f t h e c r i t er i a

l i s t ed i n t h i s app e n d ix 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 endangered

u n der t h e E S A or of 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. T he EPA must provide

confirmation that you satisfactorily completed th is screening procedure in order for you to be eligible for coverage

under the General Permit.

T hi s appendix p r o v i des y o u in f o rm a t i o n o n t h e f o ll o w in g:

• Section 1.0: Listed Species Eli g ibil i t y C r i t er ia and

• Section 2.0: G u i d anc e f o r D e t erm inin g Whic h Listed Species C r i t er ion A ppli es.



### 1.0 **Listed Species Eli**  **g i**  **b ility**  **Cr ite**  **r ia** 

To be eligible for coverage under the General Permit, y o u m u st satisfactorily complete the screening procedure and

meet o n e o f t h e e li g i bi l i t y c r i t er i a li s t e d b e l o w. Y o u m u s t al s o s p e ci fy i n your submittal t h e ba s i s f o r y ou r s e l e c t i o n o f

t h e applic a b l e e li g ib i l i t y c r i t er i o n and provide documentation supporting the criterion selected.

No t e : ( 1 ) Y o ur determination m us t p r o v i de sufficient d o c u me n t a t i o n t o s u pp o rt y o u r de t erm ina t io n t ha t yo u s a t i s fy t h e

r e q u i reme n t s o f t h e pa r t ic u la r c r i t er i o n you have selected

. ( 2 ) Whil e c oo rd ina t i o n b e tw een yo u an d t h e U

. S

. F i s h an d

Wil d li fe S erv ic e (FWS) an d / o r t h e N a t i o na l M a r in e F i s h er i es S erv ic e (NMFS; t o ge t h er, t h e “ S erv i c e s ” ) i s n o t n e c es s a r il y

re q u i red i n al l ca se s

, the EPA e nc o u r a ges y o u t o c o o rd ina t e w i t h t h e relevant Service(s) an d t o do s o e a r l y i n t h e

plannin g p r o c e s s p r i o r t o s u b m i tt in g you r Request for Coverage

.

You must comply with any applicable terms, conditions, or other requirements developed in the process of meeting

any of the eligibility criteria (A

- E) in this section to remain eligible for coverage under the General Permit.

Documentation of these requirements shall be maintained by the permittee for the duration of time the affected

emissions unit(s) is (are) covered under the General Permit.

The following is a summar y of the five eligibility criteria. See Section 2.0 for detailed instructions to determine which

criterion applies for your specific action:

**Cr ite**  **r ion**  **A :** 

N o f eder all y

- li s t ed threatened or endangered s p e ci es o r des i g na t ed c r i t i c a l ha b i t a t ( s ) of such species a re lik e l y t o o c c u r

within the action area for your project. 1

1 Action area means all areas to be affected directly or indirectly by your project and may be broader than the immediate project

area [ See, e.g. , 50 CFR 402.02].EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 14 of 23 **Cr ite**  **r ion**  **B :** 

F eder all y

- li s t ed threatened or endangered s p e ci es o r t h e i r de s i g na t ed c r i t ica l habi t a t ( s ) a re lik e l y t o o c c u r within the action

area of your source, but the construction and operation of y o u r new minor source or construction and operation of the

modification to your existing minor source is n o t lik e l y t o a dverse l y a ff e ct li s t ed t h re a t e n ed o r e n d an gered s p e ci es o r

c r i t i c a l hab i t a t . T hi s de t erm ina t i o n m a y incl u de c o n s i der a t io n o f a n y air pollution c o n t r o l s or other changes to the

construction and/or operation of your new or modified source that yo u w il l a d o p t to e n s u re t ha t construction, modification

and operation of your new or modified source are n o t l ik e l y t o a dver s e l y a f fe c t li s t ed s p e ci es or c r i t ic a l hab i t a t. To

m ak e t hi s c ert i f ic a t i o n

, y o u m u st incl u de t h e f o ll ow in g i n you r Request for Coverage documentation: ( 1 ) identify any

feder all y li s t ed s p e ci es an d /o r d e s i g na t ed critical hab i t a t l o ca t ed within the action area of your source; ( 2 ) t h e d i s t a n c e

b e tw een you r s i t e an d t h e listed species or designated critical habitat (in miles); and (3) any other information

necessary (e.g., a detailed map of the action area and supporting justification) to show that the

construction/modification and operation of your new or modified source are not likely to cause any adverse effects to the

listed threatened or endangered species or their critical habitat.

**Cr ite**  **r ion**  **C:**

C o o rd ina t i o n b et w een yo u an d t h e S erv ic e( s) ha s b een c o ncl u de d and has a ddre s sed t h e effe c t s o f y o u r new or

modified minor source’s construction/modification and operation o n fe d er all y

- li s t ed t h r e a t e n ed o r e n d an gered s p e ci es

an d feder all y

- d e s i g na t ed c r i t ica l hab i t a t. The coordination m us t re s u l t i n a w r i t t en c o nc u rre nc e f ro m t h e re l ev an t

S erv ic e ( s) t h a t you r new or modified minor source’s construction/modification and operation a re n o t lik e l y t o a dver s e l y

a ffe c t li s t ed s p e ci es o r c r i t i c a l ha b i t a t

. Y o u m us t incl u de c o pi es o f t h e c o rre s p o n de nc e b e tw een y o u r s e l f an d t h e

S e r v ic e(s) with your submittal

.

**Cr ite**  **r ion**  **D:**

Co n s u l t a t i o n b et w een another F eder a l A ge n c y an d t h e Service(s) u n d e r s e c t i o n 7 o f t h e E S A ha s b een c o ncl u de d

. T h e

c o n s u l t a t i o n m us t ha ve a ddres s ed t h e effe c t s o f your minor source’s construction/modification and operation o n

feder all y

- li s t ed t h re a t e n ed o r e n d an ge r ed s p e ci es an d feder ally

- des i g na t ed c r i t ic a l hab i t a t

. T h e re s u l t o f t hi s

c o n s u l t a t i o n m us t b e e i t h er:

1. A bi o l o g ica l o pini o n t h a t c o ncl u des t ha t t h e a c t i o n i n q u e s t i o n ( t akin g i n t o acc ou n t t h e

effe c t s o f y ou r s ource’s construction/modification and operation) i s n o t lik e l y t o

j e o pa rd i z e t h e c o n t in u ed ex i s t e nc e o f li s t ed s p e ci e s

, o r result in t h e des t r u c t i o n o r a dverse

m o d i f ica t i o n o f c r i t i ca l hab i t a t ; o r

2. Written c o nc u rre nc e f ro m t h e appl i cabl e S erv ic e ( s ) w i t h a f in d in g t h a t t h e source’s

construction/modification and operation a re n o t lik e l y t o a dver s e ly a ffe c t feder all y

- li s t ed

s p e ci es o r fed e r all y

- des i g na t ed critical habi t a t

.

Y o u m u st incl u de c o pi es o f t h e relevant documentation cited above i n y o u r submittal

.

**Cr ite**  **r ion**  **E:**

Y ou have obtained an incidental take permit from the Service(s) under section 10 of the ESA in connection with your

c o n s t r u c t i o n/modification and operation ac t i v i t i es, an d t hi s permit a ddres s e s t h e effe c t s o f t h e source o n relevantEPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 15 of 23 feder all y

- li s t ed s p e ci es an d feder all y

- des i g na t ed c r i t i ca l hab i t a t

. Y o u m u st incl u de c o pi es o f t h e incidental take permit

and associated documentation and c o rre s p o n de nc e b e tw e e n y o u r s e l f an d t h e S erv i c e(s) with your submittal

.



### 2.0 **De t**  **e r**  **mini n**  **g W**  **hich Cr**  **ite r**  **ion A**  **pp lies** 

To qualify for the General Permit, yo u need to m e et o n e o f t h e five c r i t er i a l i s t ed a b o ve . Y o u m u st f o ll o w t h e

p r o c ed u res i n S t e p s 1 t h r ou gh 5 below t o de t erm in e t h e listed species c r i t er i o n, if any, u n der w hic h y o u r project i s

e li g ibl e f o r p e r m i t c o ver a ge.

Step 1

- Determine if Previous or Separate Assessments Have Already Addressed Your Source.

You should first determine whether you are eligible to select either Criterion D or E based on an ESA section 7

consultation previously completed by another Federal Agency (Criterion D) or an ESA section 10 permit (Criterion E)

issued by the Service(s) as follows:

Meeting Criterion D : If consultation under section 7 of the ESA has been concluded in connection with another Federal

Agency’s involvement with your source, you may be eligible to select Criterion D. To be eligible to select Criterion D, you

must confirm that all the followin g are true:

• A consultation between a Federal Agency and the Service(s) under section 7 of the ESA has been concluded.

Consultations can be either formal or informal, and would have occurred in connection with a separate action by

a separate Federal Agency (e.g., as part of a separate Federal Agency’s authorization for you to construct or

operate your business in Indian country). The consultation must have addressed the effects of the construction,

modification and operation of your new or modified source o n all federally

- listed threatened or endangered

species and all federally

- designated critical habitat in your action area. The result of this consultation must be

either:

a. A biological opinion that concludes that the construction, modification and operatio n of your new or

modified source is not likely to jeopardize the continued existence of any listed species, nor result in the

destruction or adverse modification of any designated critical habitat. The consultation must have included

consideration of the e ffects of your facility’s emissions and other related activities on all listed species and

designated critical habitat in your action area; or

b. Written concurrence (e.g., letter of concurrence) from the applicable Service(s) with a finding that the

constru ction, modification and operation of your new or modified source are not likely to adversely affect

listed species or designated critical habitat. The consultation must have included the effects of your

facility’s emissions and other related activities on all the listed species and designated critical habitat in

your action area.

• The consultation remains current, in accordance with 50 CFR §402.16; or, if re

- initiation of consultation is

required (e.g., due to a new species listing or critical habitat desig nation or new information), such reinitiated

consultation is concluded, and the result of the consultation is consistent with the statements above. Attach a

copy of any consultation re

- initiation documentation from the Service(s) or other consulting Federa l Agency.

If all of the above are true, you may select Criterion D. You must also provide a description of the basis for the

criterion selected. In your submittal you must also provide the Biological Opinion (or Public Consultation Tracking

System tracki ng number) or concurrence letter and any other documentation supporting your determination.

If any of the above is not true, you may not select Criterion D. For example: if the biological opinion or written

concurrence from the Service(s) did not include t he effects of your source’s air emissions or other

- related activities asEPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 16 of 23 described above; or if the previous consultation covered some but not all of the listed species or critical habitat in your

action area; or if the consultation is no longer current (e .g., due to new species listings); then you are not eligible under

Criterion D.

Meeting Criterion E : You have obtained an incidental take permit under section 10 of the ESA, and this permit

addresses the effects of the construction/modification and operat ion of your new or modified source on federally

listed species and designated critical habitat in your action area.

You may rely on a section 10 permit that you have previously obtained so long as it addresses the

construction/modification and operation of your new or modified source and all federally

- listed species and

designated critical habitat in your action area . (Note: If you do not hold a section 10 permit already, you can

consider obtaining one ; however, it may be more efficient to instead meet the requirements for Criterion A, B or C

as described in Steps 2

– 5.)

If you choose to apply for a new section 10 permit, y o u m u s t f o ll o w applicable Service p r o c e d u res ( s ee 50 C F R

§ 1 7

. 2 2 ( b ) ( 1) f o r F W S an d §22 2

. 22 f o r N M F S )

. A pplica t i o n in s t r u c t i o n s f o r s e c t i o n 10 p erm i t s f o r F W S a n d N M F S ca n b e

o b t ain ed b y acc e s s in g t h e F W S an d N M F S w e b s i t es ( h tt p : // www

. f w s

. g o v an d h t t p : // www

. n mf s

. n o a a

. g o v ) o r b y

c o n t ac t in g t h e app r o p r ia t e F W S a n d N M F S reg i o na l o ff ic e

.

If the above is true, you may select Criterion E. You must also provide a description of the basis for the criterion

selected. In your submittal you must provide a copy of the permit issued by the Service(s).

If the above is not true, you may not select Criterion E at this time and must proceed to Step 2. For example, if a

permit has been issued under section 10 of the ESA, but the permit did not consider the effects of the facility’s air

emissions and/or emiss ion

- related activities on all federally listed species and designated critical habitat on your

species list, you are not eligible under Criterion E.

Step 2

- De t erm in e i f L i s t ed T h re a t e n ed o r En d an gered S p e ci es o r t h e i r D e s i g na t ed C r i t ica l Ha b i t a t ( s

) a re L ik e l y t o

O cc u r within the Action Area of your Minor Source.

Y o u m u s t de t erm in e, t o t h e b e s t o f y o u r kn o w l edge, w h e t h er s p e ci es federally li s t ed a s e i t h er t h re a t e n ed o r

e n d an ge r ed, o r t h e i r designated c r i t ic a l hab i t a t ( s ), a re l o ca t ed within the action area of your minor source. 2 This is a two

step process. The first step is to determine your action area. When defining the boundaries of your action area, you should

take into account the following criteria:

• Ground disturbance

– Effects during construction, maintenance and operation of the facility should be

considered.

• Changes in water quality/quantity (both surface and groundwater)

– This would include effects that may extend

far beyond the footprint of the facility. An example may be stormwater runoff from impervious surfaces

(containing sediments or other contaminants) on the site that may reach water bodies (including ditches tha t

empty into water bodies) some distance from a facility. All receiving water bodies that could receive pollutants

from the facility’s construction, maintenance, or operation should be included in the action area.

2 For definitions of terms that you might encounter when addressing the listed species requirements, go to:

http://www.fws.gov/midwest/endangered/glossary/index.html and http://www.fws.gov/northeast/nyfo/es/actionarea.htm

.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 17 of 23 • Air Quality Impacts

– Effects during cons truction, maintenance and operation of the facility should be

considered.

• Lighting effects

– Effects during construction, maintenance and operation of the facility should be considered.

• Noise Disturbance

– Effects during construction, maintenance and opera tion of the facility should be considered.

Note: If you have questions about determining the extent of the action area, you should coordinate with the

local Service field office as noted below. If site

- specific conditions exist such that the action are a would be

limited to the facility footprint, but that fact may not be obvious from a map or figure, submit a narrative

description of the action area in addition to a map for evaluation of the action area selected. To de t erm in e

t h e f i e l d o ff ic e t ha t c o rres p o n ds t o y ou r p r o je c t s i t e, v i s i t:

h t t p : // www

. f w s

. g o v / e n d an gered / reg i o n s / in de x

. h t ml an d h t t p : // www

. n mf s

. n o a a

. g o v/ ( un der t h e l eft t ab f o r

“ R eg i o n s ” )

.

After determining the boundaries of the action area, you will next de t erm ine i f li s t ed s p e ci es an d /o r c r i t ica l hab i t a t a re

ex p e c t ed t o ex i s t there. Relevant sources of information regarding the locations of listed species and critical habitats are

often organized along county and/or township lines. You should thus first identify the counties and/or townships within

which your action area is located. You would then consult relevant sources of information regarding the locations of listed

species and critical habitats. T h e l o ca l o ff ic es o f t h e F W S and N M F S o f t en m ain t a i n li s t s o f feder all y li s t ed threatened or

endangered s p e ci es o n t h e i r Internet si t es. Fo r F W S t erre s t r ia l a n d aq u a t i c s p e ci es in f o rm a t i o n

, y o u c a n u se the F W S o n

lin e m app i n g t oo l

, t h e I n f o rm a t i o n

, P lannin g, a n d Co n su l t a t i o n S y st em, l o ca t ed a t h t t p : // www

. f w s

. g o v / ipac /

.

I n m o st ca se s

, listed s p e ci es an d designated c r i t ica l hab i t a t li s t s will all o w yo u t o de t erm in e i f an y s u c h s p e ci es o r

habi t a t ex i s t s i n y o u r c o u n t y o r t o w n s h i p

. Yo u ca n al so f in d c r i t i ca l hab i t a t des i g na t i o n s an d a sso ci a t ed

re q u i reme n t s a t 50 CF R P a r t s 17 an d 22 6 (see h t t p : // www

. acc e s s

. g p o .g o v )

. You may also use the FWS Critical

Habitat Portal (see http://criticalhabitat.fws.gov/crithab/ ).

• If t h e r e ar e n o li s ted sp e cies and/or critical habitat in the coun t ies/ t o w n s hips where your action area is

located y o u m a y select Cr i t e r i o n A

. Y o u m u st al so p r o v i de a des c r ip t i o n o f t h e ba s i s f o r t h e c r i t er i o n s e l e c t ed

an d p r o v i de d o c u me n t a t i o n su pp o r t in g t h e c r i t er i o n selected in your submittal.

• I f the r e ar e li s ted sp e cies a n d /or c r itic a l h ab it a t in the coun t ies /

t o w n sh ips in your action area, y o u s h ou l d

c o n t ac t you r l o c a l F W S or N MFS office t o de t erm in e i f t h e l i s t ed sp e ci es a re kn o w n t o ex i st within the

specific action area of y o u r minor source an d i f any designated c r i t i c a l ha b i t a t a re a s o ver la p the action area of

y o u r minor source

.

o I f you r l o ca l F W S or N M F S office in d ica t es t h a t t h ese s p e ci es an d /o r c r i t ica l hab i t a t c ou l d ex i s t within the

action area of y o u r minor source

, y o u m us t do one of the following to determine if the species and/or

critical habitat may actually be present in or may use your action area :

 Co n d u c t v i su a l in s p e c t i o n s. T hi s me t h o d m a y be pa r t ic u la r l y su i t abl e f o r s i t es t h a t a re s m all er in

s i z e o r l o ca t ed i n n o n

- na t u r a l s e tt in gs s u c h a s hi g hly u r bani z ed a re a s o r in d u s t r ia l pa r k s w h ere

t h ere i s l i t t l e o r n o na t u r a l hab i t a t

.

 Co n d u c t a f o rm a l bi o l o g i ca l su rv e y

. I n so me ca s e s

, pa r t ic u la r l y f o r la rger s i t es, b i o l o g ica l s u rv e y s

m a y b e a n app r o p r ia t e w a y t o a s s e s s w h e t h er s p e ci es a re l o ca t ed within the action area of y o u r

minor source. Bi o l o g ica l su rv e y s a r e fre q u e n t ly p erf o rmed b y e n v i r o n me n t a l c o n s u l t in g f i rms. A

b i o l o g ica l su rv e y m a y i n s o me ca s e s b e u se f u l t o c o n d u c t in c o n j u nc t i o n w i t h S t e p s 3, 4 or 5 o f

t h e s e in s t r u c t i o n s.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 18 of 23 • I f, after performing one or more of the assessments above, you determine that t h e r e ar e n o li s ted sp e cies

or critical habitat in y our a ct i on ar e a

, y o u m a y select Cr i t e r i o n A. Y o u m u st al so p r o v i de a des c r ip t i o n o f t h e

ba s i s f o r t h e c r i t er i o n s e l e c t ed an d p r o v i de d o c u me n t a t i o n su pp o r t in g t h e c r i t er i o n selected in your submittal.

• If listed species or critical habitat are located in your action area

, then proceed to step 3.

Step 3

- D e t erm in e i f t h e Co n s t r u c t i o n/Modification or Operation of Your New or Modified Minor Source is L ik e l y

t o A d ver s e l y A f f

e c t L i s t ed T h re a t e n ed o r En d an gered S p e ci es o r D e s i g na t ed C r i t ica l H a b i t a t.

I f i n S t ep 2 y o u de t erm in e, ba s ed o n c o mm u nica t i o n w i th yo u r l o ca l F WS or N M F S office

, o r o t h erwise, t ha t l i s t ed

s p e ci es an d /o r c r i t i c a l habi t a t c ou l d ex i s t within the action area of your new or modified minor source

, y o u m u s t

n ext a s se s s w h e t h er the construction/modification or operation of your new or modified minor source is lik e l y t o a dver s e l y

a ffe c t li s t ed t h re a t e n ed o r e n d an gered s p e ci es o r d e s i g na t ed c r i t ica l h a b i t a t.

P o t e n t ia l a dver s e effe c t s fr o m construction/ modification and operation activities incl u de direct and indirect effects and

could include, but are not limited to, the following:

• Ha b i t a t Disturbance

. Surface disturbance activities such as e x ca v a t i o n

, s i t e deve l o p me n t, gr a d in g, and associated

light and noise m a y a dverse l y a ffe c t li s t ed s p e ci es o r t h e i r habi t a t

.

• Operation of the Source. Source operations could result in additional traffic, noise and light that could affect

species or habitat.

• Water

- Related Impacts. Changes in water usage or water discharges may affect listed species or their habitat.

• Air Emission Impacts. Increases in emission of certain pollutants may i n certain cases affect vegetation growth

patterns that can affect listed species or their habitat.

T h e s c o p e o f e ffe c t s t o c o n s i der w il l v a ry w i t h e a c h site and project

. I f yo u a re ha v in g d i ff ic u l t y de t erm inin g w h et h er

y o u r p r o je c t i s lik e l y t o a dver s e l y a ffe c t li s t ed s p e ci es o r c r i t ical habi t a t

, o r o n e o f t h e S e r v ic es ha s al re a dy r ai sed

c o nc er n s t o y o u

, y o u s h o u l d c o n t act t h e app r o p r i a t e o ff ic e o f t h e F W S or N MF S f o r a s s i st anc e.

• I f a d v e rs e e ff

e cts to li s ted th r e a tened or en da n g e r ed sp ecies or their c r itic a l h ab it a t ar e not l i kel y

, t h e n y o u

m a y s e l e c t Cr i t e r i o n B

. Y o u m u st p r o v i de t h e f o ll o w in g s p e ci f i c in f o rm a t i o n with your submittal :

1 . The feder all y li s t ed s p e ci es an d /o r d e s i g na t ed hab i t a t that a re l o ca t ed within the action area of your minor

source ;

2 . T h e d i s t anc e b et w een you r s i t e an d t h e li s t ed s p e ci e s o r des i g na t ed c r i t ica l h a b i t a t ( i n m il es ); and

3 . Any other information necessary to show that the construction/modification and operation of your source are

not likely to cause any adverse effects to the listed threatened or endangered species or their critical habitat.

• If adverse effects to listed threatened or endangered species or their critical habitat are likely, you must

follow Step 4 below.

Step 4

- D e t erm in e i f M e a s u r e s C a n B e I m pl eme n t ed t o A v o i d A d ver s e E f f

e c t s.

I f yo u de t erm ine i n S t ep 3 t ha t a dver s e effe c t s fr o m the construction/modification or operation of your new or

modified minor source are lik e l y to o c c u r

, y o u ca n s t i l l select e li g ibili t y Cr i t er i o n B i f you undertake app r o p r ia t e

me a su res t o a v o i d o r e li m ina t e t h e lik e l ih oo d o f a dve r se ef f e c t s p r i o r t o seeking c o v er a g e under the General Permit

.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 19 of 23 T h ese me a su r es m a y in v o l ve re la t i ve l y s i m pl e chan ges t o c o n s t r u c t i o n ac t i v i t i es s u c h a s re

- r ou t in g construction t o

b y pa s s a n a rea w h ere s p e ci es a re l o ca t ed, re l o ca t in g source activities

, o r m o d i f y in g t h e “ f oo t p r in t ” o f t h e site

.

• I f y ou ar e ab l e to im p le m ent appr o pr i a te me as u r es to av oid the likelihood of adv e rs e e f f

e ct s

, t h en y o u m a y

s e l e c t C r i t e r i o n B

. T h e me a s u r e s y o u a d o p t t o a v o i d o r e li m ina t e a dver s e e ffe c t s m u st b e i m pl eme n t ed f o r t h e

d u r a t i o n o f t h e c o n s t r u c t i o n/modification and operation of your new or modified minor source an d y o u r

c o v er a ge u n der t h is General Permit

. Yo u m us t al so p r o v i de a d e s c r ip t i o n o f t h e ba s i s f o r t h e c r i t er i o n s e l e c t ed,

an d t h e f o ll o w in g s p e ci f i c in f o rm a t i o n o n y o u r Request for Coverage Fo r m : (1 ) the feder all y li s t ed s p e ci es

an d /o r d e s i g na t ed hab i t a t that a re l o ca t ed within the action area of your minor source ; (2 ) t h e d i s t anc e b et w een

you r source an d t h e li s t ed s p e ci e s o r des i g na t ed c r i t ica l h a b i t a t ( i n m il es ); and (3) what steps were or will be

taken to avoid the likelihood of adverse effects.

• I f y ou c a n n ot determine sufficient me as u r es to im p l em ent to a v oid the l i kelih oo d of ad v e rs e e ff

e ct s

, y o u

m u s t f o ll o w t h e p r o c ed u r e s i n S t ep 5

.

Step 5

- Coordinate with the Service(s).

I f i n S t ep 4 y o u cann o t determine sufficient me a su res t o a v o i d t h e lik e lih oo d o f a dver s e e f fe c t s

, y o u m u s t c o n t a c t t h e

applicable Service(s)

. Yo u m a y s t il l b e e li g ibl e f o r c o ver a ge under the General Permit i f the lik e l y a dver s e ef f e c t s c an b e

a ddre s sed t h r o u gh mee t in g C r i t er i o n C

.

• Cr ite r ion C : Y o u ha ve c o o rd ina t ed w i t h t h e S erv ic e(s) an d ha ve a ddre s s ed t h e effe c t s o f the

construction/modification and operation of your new or modified minor source o n fe d er all y

- li s t ed t h re a t e n ed

o r e n d an gered s p e ci es an d feder all y

- d e s i g na t ed c r i t ica l hab i t a t. The Service(s) must provide w r i t t e n

c o nc u rre nc e t ha t the construction/modification and operation of your new or modified minor source is n o t

lik e ly t o a dverse l y a f fe c t li s t ed s p e ci es o r c r i t ica l hab i t a t

.

o I f yo u ha ve obtained the Service(s) written concurrence as described above

, then y o u m a y s e l e c t Criterion C.

As part of your submittal, y o u m u st p r o v i de a d e s c r ip t i o n o f t h e ba s i s f o r t h e c r i t er i o n s e l e c t ed an d m us t

incl u de c o p i es o f t h e c o rr e s p o n de n c e b e tw een yo u an d t h e applicabl e S erv ic e(s).EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 20 of 23 

## A **pp en**  **d i**  **x B** 

**– H**  **i s**  **to r**  **ic P**  **r o**  **p e**  **r ty**  **Sc r**  **e ening**  **P r**  **oce s**  **s**

**1.0 B a**  **ck gr**  **ound**

T h e p u r p os e o f t hi s appendix i s t o a s s i s t y o u i n completing t h e

screening procedure for addressing historic properties that are

either listed on, or eligible for listing on, the National Register for

Historic Places prior to submitting your Request for Coverage under

the General Air Quality Permit for New or Modified Minor Source

Gasoline Dispensing Facilities in Indian Country within California

(General Permit)

. I n o rder t o b e e l i g ibl e f o r c o ver a ge u n d e r the

General Permit, y o u must de m o n s t r a t e t h a t yo u qualify under o n e

o f t h e c r i t er i a l i s t ed i n t h i s app e n d ix 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 historic properties. T he EPA must provide confirmation that you

satisfactorily completed th is screening procedure in order for you

to be eligible for coverage under the General Permit.

T o a ddre s s an y i s s u e s re la t in g t o hi s t o r ic p r o p er t i es, the EPA ha s

d ev e l o p ed t h e s c ree nin g p r o c ess i n t hi s app e n d i x t o e nabl e source

owners/operators t o: (1) app r o p r ia t e ly c o n s i der t h e p o t e n t i a l

i m pac t s

, i f any

, resulting from the construction, modification, and/or operation of a new or modified emission source o n

hi s t o r ic p r o p er t i es an d, (2) if applicable, de t erm in e w h e t h er a c t i o n s ca n b e t ak e n t o m i t i g a t e an y su c h i m pac t s

. A l t h ou gh

each decision that a specific minor source meets the requirements for coverage u n der t hi s General Permit does n o t c o n s t i t u t e

a s e pa r a t e F eder a l u n der t akin g, t h e s c ree nin g p r o c ess i n t hi s app e n d i x p r o v i des a n app r o p r ia t e si t e

- s p e c i f i c me an s o f

ad dres s in g hi s t o r i c p r o p e r t y i s s u e s i n c o nn e c t i o n w i t h coverage under the General Permit

.

If the impacts from your source have already been reviewed under another Federal agency’s approval process (e.g., the

Bureau of Indian Affairs authorizing operation of your source in Indian country) then documentation from that review

may satisfy the requirement s of this section. In some cases

, the review by another agency will have evaluated the

impacts from site disturbance activities (e.g., site clearing), but not from air emissions. In such cases supplemental

evaluation may be required to complete the analys is.



### 2.0 I **n s**  **t r**  **uctions f**  **or Source Owners/**  **Op e**  **ra to**  **r s** 

Y o u a re re q u i red t o f o ll o w t h e s c ree nin g p r o c ess i n t hi s app e n d i x t o de t e r m in e i f the construction, modification or

operation of a new or modified minor source of air pollutants o n y o u r s i t e 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

, an d w h e t h er o r n o t y o u n eed t o c o n t ac t you r State Historic Preservation Officer ( S H PO)

, Tribal Historic

Preservation Officer ( T H P O)

, o r o t h er t r iba l re p r e s e n t a t i ve f o r f u r t h er in f o rm a t i o n

. Yo u must satisfactorily complete t hi s

s c ree nin g p r o c e s s to be eligible for coverage under the General Permit

. T h e f o ll o w in g f ou r s t e p s d e s c r ib e h o w

app l ica n t s ca n meet t h e hi s t o r i c p r o p erty re q u i r e me n t s u n der t hi s p erm i t

. K ey T e rm s

H

i sto r ic p r o

p

e

r ty

- pr e h i s t o r i c o r h i s t o r i c d i s t r i c t s

,

s i te s

, b u i l d i n gs

, s t r uctu r e s

, o r ob j ec t s t h a t a r e

i n c l u d e d i n o r e l i g i b l e fo r i n c l u s i o n i n t h e Na t i ona l

R e g i s ter o f H i s t o r i c P l a c e s

, i n c l u d i n g a r t i f a ct s

,

r ec or ds

, a n d r e m a i n s t h a t a r e r e l a ted to an d l o c a ted

w i t h i n s uch prop e r t i e s

S

H

PO

– T h e S t a te H i s t o r i c P r e s e rv a t i o n O f f i cer fo r

a p a r t i c u l a r s t a te

T

H

P

O o r T r ibal r e

p

r ese n

t a

t i v

e

– T h e Tr i b a l H i s t o r i c

P r e s e rv a t i o n O f f i cer fo r a p a r t i c u l a r Tr i b e or

, i f t h e r e i s

n o T H P O

, t h e r e pr e s e n t a t i v e d e s i g n a t e d b y s uch T r i b e

fo r NH P A p u rpo s esEPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 21 of 23 Step 1

- Ha ve p r i o r p r o

f

e s s i o na l c u l t u r a l re s o u r c e s u rv e y s o r o t h er ev al u a t i o n s de t e r m i n ed whether

h i

s t o r i c p r o p ert i es ex i st in the area of your proposed source? Or, have p r i o r earth d i s t u r banc es p re cl u ded

t h e ex i s t e nc e o f h i s t o r i c p r op ert i e s in the area of your proposed source?

I f it h a s al re a dy b een de t erm i n ed t h a t n o hi s t o r i c p r o p er t i es ex i st in the area of your proposed source ba s ed

o n a v ailabl e in f o rm a t i o n

, incl u d in g in f o rm a t i o n t h a t m a y b e p r o v i ded b y y o u r applica b l e S H P O

, T H P O

, o r

o t h er t r iba l re p re s e n t a t i ve, t h en yo u m a y submit the appropriate documentation of “no historic properties

affected” with y o ur submittal

, an d n o f u r t h er s c ree nin g s t e p s a re n e c e s s a r y

.

Similarly, i f e a r t h d i s t u r banc es t ha t h a ve o cc u rred p r i o r t o y o u r p r o je c t ha ve e li m ina t ed t h e p os s ibil i ty t ha t hi s t o r i c

p r o p er t i es ex i st o n y o u r s i te or in the area affected by your new or modified minor source

, t h en yo u m a y submit the

appropriate documentation of “no historic properties affected” with y o ur submittal

, an d n o f u r t h er s c ree nin g s t e p s a re

n e c e s s a r y

.

During the EPA’s review process , the SHPO, THPO, or other tribal representative may request that the EPA deny

coverage under the General Permit based on concerns about potential adverse impacts to historic properties. The EPA

will evaluate any such request and notify you if any additional information is needed to address adverse impacts to

historic properties.

S t ep 2

- I f yo u a re constructing or modifying a minor source of air pollutants, as defined in 40 CFR §49.152

, yo u

m us t d e t erm in e i f the construction, modification or operation of the minor source w i l

l ha ve a n ef f

e c t o n

h i

s t o r i c p r o p ert i es.

I f you r an s w er t o t h e q u e s t i o n s i n S t e p 1 i s “n o, ” t h en y o u m us t a s s e s s w h e t h er the ac t i v i t i es re la t ed t o t h e

construction, modification or operation of your new or modified minor source w i l l ha ve a n e ff e c t o n h i s t o r i c p r o p ert i e s.

Activities that could have an adverse effect on historic properties could include, for example:

• Excavations;

• Demolitions of existing buildings;

• Construction of f oundations (e.g., for buildings, tanks or stacks);

• Installations of underground tanks;

• Addition of impervious surfaces; and

• Increases in truck traffic during excavation, demolition, or construction.

No t e : T h i s l i s t i s n o t i n t e n ded t o b e ex ha us t i ve. Ot h er activities t ha t a re n o t o n t h i s l i st m a y in v o l ve e a r t h

- d i s t u r b i n g

a c t i v i t i es an d m u s t al so b e ex a m i n ed f o r t h eir p o t e n t i a l t o a f f

e c t h i s t o r i c p r o p ert i e s . For more information, go to the

National Park Service, National Register of Historic Places database found at

http://www.nps.gov/history/nr/research/index.htm

.

T he a s se ss m e n t m a y b e ba s ed on a site map of your source and an analysis of h i s t o r i c a l sou r c e s

, kn o w l edge o f t h e a re a

,

a n a s se s s m e n t o f t h e t y p es o f a c t i v i t i es yo u a re e n g a g i n g in

, c o n s i der a t i o n s o f an y c o n t r o l s an d / o r m ana ge m e n t

p r ac t ic es y o u w i l l a d o p t t o e n su re t ha t y o u r a c t i v i t i es w i l l n o t h a ve a n e ff e c t o n h i s t o r i c p r o p ert i es, an d any o t h er

re l ev an t f ac t o rs.

I f y o u de t er m in e ba sed o n t h i s a s s es s m e n t t h a t the activities re la t ed t o t h e construction, modification or operation of

your new or modified minor source w i l l n o t ca u se e ff e c t s to h i s t o r i c p r o p ert i e s

, t h en yo u m a y submit the appropriate

documentation of “no historic properties affected” with y o ur submittal

, an d n o f u r t h er s c ree nin g s t e p s a re n e c e s s a r y

.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 22 of 23 During the EPA’s review process , the SHPO, THPO, or other tribal representative may request that the EPA delay your

coverage under the General Permit based on concerns about potential adverse impacts to historic properties. The EPA

will evaluate any such request and notify you if any additional information is needed to address adverse impacts to

historic properties.

I f yo u a re in s t allin g or modifying equipment that ha s t h e p o t e n t i a l t o ha ve a n adverse effe c t o n hi s t o r i c p r o p er t i es, t he n

y o u m u st p r o c eed t o S t ep 3.

Step 3

- I f yo u a re constructing or modifying a minor source an d y o u ha v e n o t s a t i sf

i ed t h e c o n d i t i

o n s i n S t e p s

1

- 2

, yo u m us t c o n t ac t a n d c o n su l t w i t h t h e app r o p r i a t e h i s t o r i c p re s erv a t i o n a u t h o r i t i es.

Wh ere y o u a re constructing or modifying a minor source an d y o u cann o t de t erm in e i n S t ep 2 t h a t t his ac t i v i ty w il l n o t

ha ve effe c t s o n hi s t o r ic p r o p er t i e s

, t h en y o u m us t c o n t ac t t h e re l ev a n t S H P O

, T H P O

, o r o t h er t r iba l r e p re s e n t a t i ve t o

re q u est t h e i r v i e w s a s t o t h e lik e lih oo d t h a t hi s t o r i c p r o p er t i es m a y b e adversely affected b y t h e construction,

modification or operation o f your new or modified minor source

.

No t e : A ddre s s es f o r S H P O s an d T H POs m a y b e fo u n d o n t h e A dv i s o r y C o un c i l o n H i s t o r i c Preserv a t i o n ’s (ACHP’s) w e b s i t e

( http://www.achp.gov/programs.html )

. I n i n s t a n c es w h ere a tr i b e d o es n o t ha ve a T H PO, y o u s h o u l d c o n t ac t t h e

app r o p r ia t e T r iba l g o ver n m e n t o ff

i c e des i g n a t ed b y t h e t r i b e f o r t h i s p u r p os e w h en re s p o n d i n g t o t h i s p e r m i t e l i g i b i l i t y

c o n d i t i o n

.

Y o u m u st su b m i t t h e f o ll o w in g m i n i m u m in f o rm a t i o n i n o rder t o p r o p er l y ini t ia t e you r re q u e s t f o r in f o rm a t i o n :

1. Project name (i.e., the name or title most commonly associated with your project);

2. A narrative description of the project;

3. Name, address, phone and fax number, and email address (if available) of the operator;

4. Most recent U.S. Geological Survey map section (7.5 minute quadrangle) showing actual project location and

boundaries clearly indicated; and

5. Sections of sit e map that show locations where activities might cause an adverse effect on historic properties.

Wi t h ou t s u b m i t t in g t hi s m i ni m u m in f o rm a t i o n

, y o ur request cannot be considered. Yo u w il l n eed t o p r o v i de t h e

S H P O

, T H PO

, o r o t h er t r iba l re p rese n t a t i ve a m ini m u m o f 15 cal e n d a r d a y s a f t er t h ey re c e i ve t h ese m a t er ial s t o

res p o n d t o y o u r re q u est f o r in f o rm a t i o n ab ou t y o u r p r o je c t

. Y o u a re a dv i sed t o get a r e c e ip t fr o m t h e p o st o ff ic e o r

o t h er ca rr i er c o n f i rm in g t h e d a t e o n w h i c h y o u r l e tt er w a s re c e i v ed.

I f yo u d o n o t re c e i ve a r e s p o n s e w i t hin 15 cal e n d a r d a y s a f t er re c e ip t b y t h e S H P O

, T H PO

, o r o t h er t r iba l re p re s e n t a t i ve

o f y o u r re q u e s t

, t h en y o u m a y in d ica t e t h i s in your submittal

, an d n o f u r t h er s c ree nin g s t e p s a re n e c e s s a ry

. O r

, i f t h e

applicabl e S H PO, T H P O

, o r o t h er t r ib a l re p rese n t a t i ve re s p o n ds t o y o u r re qu est w i t h a n i n d ica t i o n t h a t n o hi s t o r i c

p r o p er t i es w i l l be adversely a ffe c t ed b y t h e construction or modification of your minor source

, t h en yo u m a y submit the

appropriate documentation of “no adverse effects” with y o ur submittal

, an d n o f u r t h er s c ree nin g s t e p s a re n e c e s s a r y

.

If within 15 calendar days of receipt of your request the applicable SHPO, THPO, or other tribal representative

responds with a request for additional information or for further consultation regarding appropriate measures for

treatment or mitigation of effects on historic properties caused by the construction, modification or operation of your

minor source, you must comply with this request and proceed to Step 4.EPA Form No. 6700

- 06

EPA ICR No. 1230.27

OMB Control No. 2060

- 0003

Approval expires 4/30/2017

Request for Coverage:

Gasoline Dispensing Facilities within California Page 23 of 23 During the EPA r eview process , the SHPO, THPO, or other tribal representative may request that the EPA place a hold

on authorization based on concerns about potential adverse impacts to historic properties. The EPA will evaluate any

such request and notify you if any addi tional information is needed to address adverse impacts to historic properties

before continuing review of your Request for Coverage under the general permit.

Step 4

- Co n s u l t a t i o n w i th you r app l i ca b l e S H PO, T H PO, o r o t h er t r i b a l re p rese n t a t i v e.

I f, f o ll o w in g y o u r d i s c us s i o n s w i t h t h e app r o p r ia t e h i s t o r i c p reserv a t i o n a u t h o r i t i es i n S t ep 3, t h e applicabl e S H P O

, T H P O

,

o r o t h er t r iba l re p r e se nta t i ve re q u es t s a dd i t i o na l in f o rm a t i o n o r f u r t h er c o n s u l t a t i o n

, y o u m us t res p o n d w i t h s u c h

in f o rm a t i o n o r c o n s u l t to de t erm in e i m pac t s and appropriate measures to mitigate such impacts t o hi s t o r i c p r o p er t i es

t ha t m a y b e cau sed b y t h e construction, modification or operation of your new or modified minor source s i t e. If after

consultation it is determined that there will be no adverse effects to historic properties, t h en yo u m a y submit the

appropriate documentation of “ no adverse effects” with y o ur submittal , and no further screening steps are necessary. I f a s

a re s u l t o f y ou r d i s c us s i o n s w i t h t h e app li cabl e S H P O

, T H P O

, o r t r iba l re p re s e n t a t i ve, y o u e n t er i n t o

, an d c o m ply w i t h

, a

w r i tt en a greeme n t reg a rd in g t re a t me n t a n d /o r m i t i g a t i o n o f i m pac ts o n y o u r s i t e, t h en yo u m a y submit the appropriate

documentation of “ adverse effects ” with y o ur submittal

.

I f, h o w ever, a greeme n t o n a n app r o p r ia t e t re a tme n t o r m i t i g a t i o n pla n c ann o t be re ach ed b e tw een yo u a n d t h e S H P O

,

T H PO

, o r o t h er t r iba l re p re s e n t a t i ve w i t hi n 30 d a y s o f y o ur re s p o n se t o t h e S H PO

, T H P O

, o r o t h er t r iba l

re p rese n t a t i ve’s re q u est f o r a d d i t i o na l in f o rm a t i o n o r f u r t h er c o n s u l t a t i o n

, y o u m a y s u b m i t y o u r screening process

documentation, b u t y o u m u st in d ica t e t h a t yo u ha ve n o t n eg o t ia t ed me a s u res t o a v o i d o r m i t i g a t e su c h e f fe c t s. Yo u

m u st al so incl u de the following with your submittal :

1. Copies of any written correspondence between you and the SHPO, THPO, or other tribal representative; and

2. A description of any significant remaining disagreements as to mitigation measures between you and the SHPO,

THPO, or o ther tribal representative.

During the EPA ’s review period , the SHPO, THPO, ACHP or other tribal representative may request that the EPA place a

hold on confirmation based upon concerns regarding potential adverse effects to historic properties. The EPA, in

coordination with the SHPO, THPO, ACHP or other tribal representative, will evaluate any such request and notify you if

any additional measures to address potential adverse effects to historic properties are necessary.