FORM A-1

COMPANY INFORMATION

I. Parent Company / Legal Corporate Owner Information

1. Legal Parent Company / Legal Corporate Name

2. Mailing Address

3. City

4. State

5. Zip Code

6. County

7. Size of Company (approximate number of employees 

including all subsidiaries, branches, and related 

establishments owned):

Page 1 of 1

DRAFT PVC Section 114 Survey Part 1

06/23/2009
FORM A-2

FACILITY INFORMATION

II. Polyvinyl Chloride and Copolymers (PVC) Production Facility Information

1. Facility Name

Facility Address

a. Street

b. City

c. State

d. Zip Code

e. County

Facility Coordinates (Decimal Degrees to the 5th decimal place)

f. Latitude

g. Longitude

2. Number of employees attached to the PVC 

production facility:

III. Technical Contact

1. Name

2. Technical Contact Title

3. Telephone

4. Facsimile

5. Email

IV. Other

1. Is the facility a major source of HAP?

2. If No, did the facility take a limit of its 

potential HAP emissions to avoid classification 

as a major source?

3. If the facility took a limit of its potential HAP 

emissions to avoid classification as a major 

source, provide the date on which the limit was 

taken (MM/DD/YYYY).

4. Does the facility manufacture other products 

in addition to PVC resin?

5. If Yes, list the other products manufactured 

at the facility.

6. Are there any HAP emissions associated 

with any co-located facilities?

Page 1 of 1

DRAFT PVC Section 114 Survey Part 1

06/23/2009
FORM D-2

30 DAY RESIN SAMPLING - STRIPPER OUTLET(S)

Instructions

2. Do not submit partial data for any day: each day must include (at a minimum) concentration analysis results for all HA

3. Complete columns 1 through 30. Enter the sample date, resin type, daily resin production, number of samples compo

4. Provide the total daily production from the resin strippers samples for the type of resin. If your final product is sold as a 

4. Enter any other HAP expected to be present (that are not listed in Table 10 to Subpart HHHHHHH of 

5. For compounds that were not detected, indicate as such in the "Non-Detect?" column and provide the method detecti

6. Enter any notes or additional information relevant to the sampling or analysis.

7. Refer to Attachment B of Enclosure 1 "Summary of Test Procedures, Methods, and Reporting Requirements For Res

CAS No. HAP

107211 Ethylene glycol

67561 Methanol

75070 Acetaldehyde

50000 Formaldehyde

51285 2,4-dinitrophenol

98862 Acetophenone

117817 Bis(2-ethylhexyl) phthalate (DEHP)

123319 Hydroquinone

108952 Phenol

79345 1,1,2,2-tetrachloroethane

106990 1,3-butadiene

540841 2,2,4-trimethylpentane

71432 Benzene

108907 Chlorobenzene

67663 Chloroform

126998 Chloroprene

98828 Cumene

75003 Ethyl chloride (Chloroethane)

100414 Ethylbenzene

107062 Ethylene dichloride (1,2-Dichloroethane)

75343 Ethylidene dichloride (1,1-Dichloroethane)

74873 Methyl chloride (Chloromethane)

75092 Methylene chloride

110543 n-Hexane

108883 Toluene

71556 Methyl chloroform (1,1,1-Trichloroethane)

79005 1,1,2-Trichloroethane

If Other, Please Provide a Description of the Resin Type -->

Number of Resin Strippers Sampled to Obtain Composite

Number of Samples Composited for Analysis

Total Daily Resin Production Rate (lbs of resin per day from sampled resin strippers)

Resin Type (suspension, dispersion, bulk, etc.) -->

1. Complete the table below for each resin type produced by the facility during the 30 days of sampling. If the facility prod

not enter data for multiple resin types on a single worksheet.
108054 Vinyl acetate

593602 Vinyl bromide

75014 Vinyl chloride

75354 Vinylidene chloride (1,1-Dichloroethylene)

1330207 Xylenes (isomers and mixtures)
st include (at a minimum) concentration analysis results for all HAP in Table 10 to Subpart HHHHHHH of 40 CFR Part 63.

date, resin type, daily resin production, number of samples composited, number of resin strippers sampled, analysis date, lab report ID, and 

pers samples for the type of resin. If your final product is sold as a dried resin, report production on a dry basis. If your final product is sold as 

re not listed in Table 10 to Subpart HHHHHHH of 40 CFR Part 63) in the table below.

such in the "Non-Detect?" column and provide the method detection limit, in ppmw, in the "Concentration (ppmw)" column.

 the sampling or analysis.

Test Procedures, Methods, and Reporting Requirements For Resin and Process Wastewater Sampling and Analysis at Polyvinyl Chloride a

Analysis Method Concentration 

(ppmw) Non-Detect?

SW-846-8015C

SW-846-8015C

SW-846-8315A

SW-846-8315A

SW-846-8270D

SW-846-8270D

SW-846-8270D

SW-846-8270D

SW-846-8270D

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

SW-846-8260B

her, Please Provide a Description of the Resin Type -->

Lab Sample ID -->

Lab Report ID -->

mber of Resin Strippers Sampled to Obtain Composite

Analysis Date -->

Number of Samples Composited for Analysis

ate (lbs of resin per day from sampled resin strippers)

Resin Type (suspension, dispersion, bulk, etc.) -->

Sample Date -->

ced by the facility during the 30 days of sampling. If the facility produced more than one resin type during the 30 days, create multiple copies 
SW-846-8260B

SW-846-8260B

EPA Method 107

SW-846-8260B

SW-846-8260B
Subpart HHHHHHH of 40 CFR Part 63.

 resin strippers sampled, analysis date, lab report ID, and lab sample ID. Enter the concentration results for each HAP listed.

ort production on a dry basis. If your final product is sold as a wet resin report production on a wet basis.

, in the "Concentration (ppmw)" column.

Wastewater Sampling and Analysis at Polyvinyl Chloride and Copolymer (PVC) Facilities" for additional instructions and information.

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

1 2

 one resin type during the 30 days, create multiple copies of this worksheet as necessary and complete one worksheet for each resin type. D

 and information.

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

3

heet for each resin type. Do 

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

4 5

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

6

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

7 8

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

9

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

10 11

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

12

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

13 14

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

15

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

16 17

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

18

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

19 20

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

21

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

22 23

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

24

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

25 26

Concentration 

(ppmw) Non-Detect? Note(s) Concentration (ppmw) Non-Detect?

27

Note(s) Concentration 

(ppmw) Non-Detect? Note(s)

28 29

Concentration 

(ppmw) Non-Detect? Note(s)

30

FORM H

EQUIPMENT LEAKS

Instructions

1. Submit a copy of the leak detection and repair procedures for the PVC production facility and provide responses to the questions below.

2. Refer to "Enclosure 1" for additional instructions and details.

Table 1. LDAR Program

Table 2. Equipment Counts

In Source 

Category

Subtotal of Equipment Associated 

with Closed Vent System(s)

(Subset of count in source category)

In heavy liquid service

In gas, vapor, and light liquid service

Connectors

In heavy liquid service

In gas, vapor, and light liquid service

Agitators

In liquid service

In gas and vapor service

Pressure Relief Devices

Open ended valves and lines

Sampling connection systems

Compressors

Instrumentation systems

Valves

In heavy liquid service

In light liquid service

Pumps

40 CFR Part 61, Subpart V

Other Federal LDAR Regulation

Specify: 

State LDAR Regulation

Specify:

Provide the total cost to your facility for conducting the LDAR 

program at this process unit in 2013:

Equipment

In heavy liquid service

In gas, vapor, and light liquid service

Is there an equipment leak detection and repair (LDAR) 

program for all equipment at your facility included in the 

source category?

If "No," how are equipment leaks detected and repaired?

If "Yes," is the equipment subject to the requirements of:

40 CFR Part 63, Subpart UU

Page 1 of 1

DRAFT PVC Section 114 Survey Part 1

06/23/2009
FORM K-1

TANKS, VESSELS AND PORTABLE CONTAINERS USED FOR FEEDSTOCK STORAGE, PRODUCT STORAGE, VENT GAS STORAGE, HOLDING, AND WASTEWATER

Instructions

1. Complete this form for 2013 only.

2. Provide copies of estimation worksheets and any other relevant documentation.

3. Complete this form for individual equipment, including equipment that is not assigned an equipment ID (e.g., portable containers).

4. Do not include gas holders on this form. Complete Form K-2 for gas holders.

4. Refer to "Enclosure 1" for additional instructions and details.

Table 1.

Table 2.

Vapor Pressure Total Emissions

(in H2O) Minimum Maximum Average (pounds)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

(select HAP)

If Other, please specify, being as descriptive as possible:

Source Process Equipment ID (if applicable):

Equipment Description:

If not provided in the equipment description above, 

describe the tank, vessel, or container and indicate (if 

applicable) if the tank is a fixed, floating internal, or floating 

external roof. 

Select the purpose of the equipment:

If Yes, How Are The Emissions Controlled?

Concentration (ppmvd @ 3% O2)

How is the HAP Concentration Determined?

Are HAP Emissions Controlled?

Individual HAP Present

Source Equipment Type:

Number of turnovers:

Equipment volume (m3):

Notes

Storage Temperature (°F)

Page 1 of 1

DRAFT PVC Section 114 Survey Part 2

06/23/2009
FORM L

STARTUP, SHUTDOWN, AND MALFUNCTION

Instructions

1. Complete this form for 2013 only.

2. Submit with your response to this survey, copies of all records of emissions during periods of process startup, shutdown, and malfunctions for 2013 only.

3. Refer to "Enclosure 1" for additional instructions and details.

For a malfunction:

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

(select HAP) (pounds)

Total Emissions During Startup, Shutdown, 

or Malfunction Event

Were all of the emissions control devices 

operating for the entire duration of the startup, 

shutdown, or malfunction event?

Startup, Shutdown or Malfunction?

If startup or shutdown, what was the 

duration (hours):

Provide a short description of 

the malfunction and the 

circumstances:

If No, which control devices were not operating 

(Control Equipment ID), for how long, and why:

Were permitted emissions limits exceeded?

Provide a description of the 

procedures used to alert the 

owner/operator that the 

malfunction occurred. If the malfunction resulted in 

a release of emissions, 

describe any indicators used 

to signal and/or measure the 

release.

Is there a written startup, shutdown and/or 

malfunction plan for the process unit?

Provide a description of the systems and 

equipment in place that function to notify 

operators that a malfunction is occurring .

Applicable standard or regulation:

Describe what actions, if any, were taken to 

minimize emissions to the atmosphere:

Page 1 of 1

DRAFT PVC Section 114 Survey Part 1

06/23/2009