### EPA Form 5900-01 OMB No. 2060-0336, Approval Expires

04/30/2012 

### Federal Operating Permit Pr ogram (40 CFR Part 71)

6-MONTH MONITORING REPORT (SIXMON)

Section A (General Information)

Permit No. ____________________

Reporting Period: Beg.____/____/________ End.____/____/_______

Source / Company Name ___________________________________________________________

Mailing Address: Street or P.O. Box ________________________________________________

City ________________________________________ State______ ZIP__________ - ______

Contact person __________________________________ Title ___________________________

Telephone (______) ______ - __________ Ext. ________

Continued on next page

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EPA Form 5900-01 2

Section B (Monitoring Report)

Summarize all required monitoring, data, or analyses required by the permit for the reporting period. Describe and cross-reference the permit term and list t he emission units (Unit IDs) where the monitoring was performed. Indicate whether a separate monitoring report is required, and if required, enter the date submitted. If submitted for the first time as an attachment to this form, assign an attachment ID, mark the attachment with that ID, and attach the report to this form.

Monitoring, Data, or Analysis (describe and cite):

Emission Units (Unit IDs):

Separate Report? ___ Yes ___ No Date____/___/________ Attachment ID _________

Monitoring, Data, or Analysis (describe and cite):

Emission Units (Unit IDs):

Separate Report? ___ Yes ___ No Date____/___/________ Attachment ID _________

Monitoring, Data, or Analysis (describe and cite):

Emission Units (Unit IDs):

Separate Report? ___ Yes ___ No Date____/___/________ Attachment ID _________

Monitoring, Data, or Analysis (describe and cite):

Emission Units (Unit IDs):

Separate Report? ___ Yes ___ No Date____/___/________ Attachment ID _________

Monitoring, Data, or Analysis (describe and cite):

Emission Units (Unit IDs):

Separate Report? ___ Yes ___ No Date____/___/________ Attachment ID _________

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EPA Form 5900-01 3

Section C (Deviations Already “Promptly” Reported)

Summarize all deviations from permit terms already reported on form PDR during the reporting period. Copy this page as many times as necessary to include all such deviations. Describe and crossreference the permit terms and report the start and end dates and times of the deviations (mo/day/yr, hr:min). Use the 24-hour clock. Also specify the date when the written deviation report was submitted to the permitting authority (If written report required, but not submitted, leave the date field blank). Note that failure to submit a deviation report, or late submittal, is a deviation that must be reported in the

Section D.

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

Permit Term for Which There was a Deviation:

Emission Units (unit IDs):

Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____

Date Written Report Submitted ____/____/________

### SIXMON

EPA Form 5900-01 4

Section D (Deviations Reported Semiannually)

This section is for deviations reported for the first time in this six-month monitoring report. Describe and cross-reference the permit terms and emission units that apply to the deviation. Copy this page as many times as necessary to include all such deviations. Report the beginning and ending times (mo/day/yr, hr:min) for each deviation. Use the 24-hour clock. Briefly explain (if known) the probable cause of each deviation. If any corrective actions or preventative measures have been taken to avoid these in the future, briefly describe the measures, including when they occurred.

Permit Term (for Which There is a Deviation):

Emission Units (unit IDs)

Deviation Start: ____/____/________ ____ :____ End: ____/____/_______ ____:____

Probable Cause of Deviation:

Corrective Actions or Preventative Measures Taken:

Permit Term (for Which There is a Deviation):

Emission Units (unit IDs)

Deviation Start: ____/____/________ ____:____ End: ____/____/_______ ____:____

Probable Cause of Deviation:

Corrective Actions or Preventative Measures Taken:

Permit Term (for Which There is a Deviation):

Emission Units (unit IDs)

Deviation Start: ____/____/________ ____:____ End: ____/____/_______ ____:____

Probable Cause of Deviation:

Corrective Actions or Preventative Measures Taken:

### SIXMON

EPA Form 5900-01 5

INSTRUCTIONS FOR SIXMON

6-MONTH MONITORING REPORT

Information Collection Burden Estimates

The public reporting and recordkeeping burden for this collection of information is estimated to average 221 hours per respondent per year. 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 Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

DETAILED INSTRUCTIONS

Section A (General Information)

The contact person should be a person familiar with the day-to-day operation of the facility, such as a plant site manager, who should be available to be contacted by the permitting authority. If there is more than one contact person, list the others on an attachment.

Section B (Monitoring Report)

Summarize all monitoring required during the repor ting period and provide information on any separate monitoring reports submitted at this time or any time during the reporting period. Each individual monitoring requirement should be included in a separate row of the table. Copy section C of this form as many times as necessary to address all monitoring requirements.

Describe and cross-reference the relevant permit term that requires monitoring, data collection or analysis. Be specific with regard to test methods or analytical techniques used, and the air pollutant or parameter monitored. The cross-reference to the permit term should be as precise as possible.

Monitoring is a method of assuring compliance with permit terms. Monitoring may include instrumental or non-instrumental methods, including continuous emissions monitoring, periodic readings of parameters related to operating conditions, stack tests using EPA reference test methods, vendor or laboratory analytical testing, manual inspections, visual observations, work practice checks, and recordkeeping that confirms a requirement has been met.

You may list multiple units if all are subject to the same monitoring requirements. In addition, for monitoring that applies to the permitted facility as a whole or to all units at your source, you may enter

A facility-wide @ in the emissions unit column.

Indicate whether a separate report is required for the monitoring described above. If a separate report was submitted prior to the submittal of this form, indicate the date; if it is being submitted for the first time with this form, assign an attachment ID in the space provided, mark the attachment accordingly, and attach the separate monitoring report to this form.

Section C (Deviations Already “Promptly” Reported)

Summarize all deviations from permit terms reported in writing prior to the submittal of this monitoring report, such as those reported using PDR . Include all deviations that were required to be reported, but not reported or not reported by the deadline. Note that all deviations that occurred during the reporting period should either be reported in this section or in section D.

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EPA Form 5900-01 6

Deviations from permit terms occur when any per mit term is not met, including emission control requirements and compliance assurance methods (monitoring, recordkeeping, and reporting). For example, the following are examples of deviations: (1) emissions that exceed an emission limit; (2) parameter value that indicates that an emission limit has not been met; (3) observations or data that show noncompliance with a limitation or other r equirement; (4) an exceedance or excursion as defined in 40 CFR part 64 (CAM); (5) required monitoring that is not performed; and (6) failure to submit a report. You also must include deviations from permit terms that occur during startup, shutdown, malfunction, and upset conditions. A deviation is not necessarily a violation; violations will be determined by EPA (or its delegate Agency).

You may list multiple emission units here if they all had deviations of this permit term and they all occurred during the same time periods. In addition, you may enter A facility-wide @ in the emissions unit column, if appropriate.

You may indicate continuous periods of deviation that span multiple days in a single entry. Use the 24-hour clock (equivalent to military time) for reporting these times (e.g., the day starts and ends at midnight, 12 a.m., or 00:00 in military time.

Specify the date when the written deviation report was submitted to the permitting authority. Leave the date field blank if you did not submit a written report during the reporting period.

It is a deviation to submit a required deviation report (whether required by telephone, fax, or in writing within 24 or 48 hours) after the deadline or to neglect to submit it at. Such deviations must be reported

in Section D.

“Emergencies” (as defined in part 71) are also considered deviations. However if the reporting requirements of part 71 for emergences are met, they may not necessarily result in noncompliance. Note that although the terms A upset, @ A startup, @ A shutdown, @ and A malfunction @ refer to conditions that are not defined in part 71, the applicable requirements may define these terms, and all deviations during such conditions are deviations. Also note that the applicable requirement itself may define the

term A deviation @ or refer to A excess emissions; @ and any such occurrences should also be reported

as deviations on this form.

Section D (Deviations Reported Semiannually)

Report those deviations required to be reported for the first time in this 6-month monitoring report. Note that all deviations not included in section C should be included here. Copy this page as many times as necessary to report all such deviations.

Cross-reference the permit term for which there is a deviation and describe the requirement.

List the emission units (Unit IDs) where this deviation occurred. You may list multiple units here if they all had deviations of this permit term and they all occurred during the same time periods. In addition, for deviations of permit terms that impose requirements to the permitted facility as a whole or to all units at your facility, you may enter A facility- wide @ in the emissions unit column.

Identify the time period (beginning and ending) over which the deviation occurred. You may indicate continuous periods of deviation that span multiple days in a single entry. Use the 24-hour clock (equivalent to military time) for reporting these times (e.g., the day starts and ends at midnight, or 00:00 in military time.

Briefly explain the probable cause of the deviation from permit terms, if known. Examples of possible answers to this question include A operator error @ or A mechanical failure. @ Be as specific as possible.

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If any corrective actions or preventative measures we re taken to avoid similar deviations at the same emissions units, briefly explain them. Exampl es of possible answers to this question include A trained operator on proper operation of control devices @ or A repaired defective equipment and will perform

routine maintenance on an accelerated schedule. @ If known, include dates when such actions or

measures were taken or will be taken in the future.

Form CTAC (Certification of Truth, Accuracy, and Completeness by Responsible Official)

You must complete form CTAC and attach it to this monitoring report.