## 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, 2010Standard 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 w as 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 Emi ssions Emission Limit Exceeded Record Keeping Failure

Marine Vessel Opacity Flaring Other:

(f) Unavoidable Emissions:

Do you intend to assert that these excess emissions w ere 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 sect ion 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 Devi ation:



### 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. S ubmi ssion 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.