DEPARTMENT OF ENVIRONMENTAL 

CONSERVATION

Standard Permit Condition IV – Notification Form

Permit Condition for Air Quality Permits

Adopted by Reference in 18 AAC 50.346

April 1, 2002

REVISED September 27, 2010
Standard Permit Condition IV – Notification Form April 1, 2002

Revised September 27, 2010 2

ADEC Notification Form

Excess Emissions and Permit Deviation Reporting

State of Alaska Department of Environmental Conservation

Division of Air Quality

______________________________________________________ ________________________

Stationary Source (Facility) Name Air Quality Permit Number

_____________________________________________

Company Name

When did you discover the Excess Emissions/Permit Deviation? 

Date: / / Time: :

When did the event/deviation? 

Begin: Date: / / Time: : (please use 24hr clock)

End: Date: / / Time: : (please use 24hr clock)

What was the duration of the event/deviation: : (hrs:min) or days 

(total # of hrs, min, or days, if intermittent then include only the duration of the actual 

emissions/deviation)

Reason for notification: (please check only 1 box and go to the corresponding section)

Excess Emissions Complete Section 1 and Certify

Deviation from Permit Conditions Complete Section 2 and Certify

Deviation from COBC, CO, or Settlement Agreement Complete Section 2 and Certify

Section 1. Excess Emissions

(a) Was the exceedance Intermittent or Continuous 

(b) Cause of Event (Check one that applies):

Start Up/Shut Down Natural Cause (weather/earthquake/flood)

Control Equipment Failure Scheduled Maintenance/Equipment Adjustments

Bad fuel/coal/gas Upset Condition Other

(c) Description

Describe briefly what happened and the cause. Include the 

parameters/operating conditions exceeded, limits, monitoring data and 

exceedance.

(d) Emission Units Involved:

Identify the emission units involved in the event, using the same identification number and name 

as in the permit. Identify each emission standard potentially exceeded during the event and the 

exceedance. 

Unit ID Emission Unit Name Permit Condition Exceeded/Limit/Potential 

Exceedance

(e) Type of Incident (please check only one):
Standard Permit Condition IV – Notification Form April 1, 2002

Revised September 27, 2010 3

Opacity % Venting (gas/scf) Control Equipment Down

Fugitive Emissions Emission Limit Exceeded Record Keeping Failure

Marine Vessel Opacity Flaring Other:

(f) Unavoidable Emissions:

Do you intend to assert that these excess emissions were unavoidable? YES NO

Do you intend to assert the affirmative defense of 18 AAC 50.235? YES NO

Certify Report (go to end of form)
Standard Permit Condition IV – Notification Form April 1, 2002

Revised September 27, 2010 4

Section 2. Permit Deviations

(a) Permit Deviation Type (check one only) (check boxes correspond with sections in permit)

Source Specific

Failure to monitor/report 

General Source Test/Monitoring Requirements 

Recordkeeping/Reporting/Compliance Certification

Standard Conditions Not Included in Permit

Generally Applicable Requirements

Reporting/Monitoring for Diesel Engines

Insignificant Source

Facility Wide

Other Section: (title of section and section # of your permit)

(b) Emission Units Involved:

Identify the emission units involved in the event, using the same identification number and name 

as in the permit. List the corresponding Permit condition and the deviation.

Unit ID Emission Unit Name Permit Condition /Potential Deviation

(c) Description of Potential Deviation:

Describe briefly what happened and the cause. Include the 

parameters/operating conditions and the potential deviation.

(d) Corrective Actions:

Describe actions taken to correct the deviation or potential deviation and to prevent future 

recurrence.

Certification:

Based on information and belief formed after reasonable inquiry, I certify that the 

statements and information in and attached to this document are true, accurate, and 

complete.

Printed Name:______________________________Title_____________________Date ______

Signature:_________________________________ Phone number_______________________
Standard Permit Condition IV – Notification Form April 1, 2002

Revised September 27, 2010 5

NOTE: This document must be certified in accordance with 18 AAC 50.345(j)

To Submit this report:

1. Fax this form to: 907-451-2187

Or

2. E-mail to: DEC.AQ.airreports@alaska.gov

if faxed or e-mailed, 

Or

3. Mail to: ADEC

Air Permits Program

610 University Avenue

Fairbanks, AK 99709-3643

Or

4. Phone notifications: 907-451-5173.

Phone notifications require written follow up report.

Or

5. Submission of information contained in this report can be made electronically at the 

following website:

https://myalaska.state.ak.us/dec/air/airtoolsweb/

if submitted online, report must be submitted by an authorized E-Signer for the Stationary 

Source.