Form Approved 03/28/2011 OMB Control No. 2060-0657 Approval Expires 03/31/2016

Field Name Field Optional or Required for ICR Test Request Note: Facility Name Required Plant Name as reported in the Component 1 Reporting Tool. Address Optional City Optional State/Zip Optional Address Optional City Optional State/Zip Optional Contact Optional Phone Optional Fax Optional Email Optional AFT Number Optional Industry NAICS Optional FRS Optional Latitude Optional Longitude Optional Testing Company (TC) Required TC Address Required TC City Required TC State/Zip Required TC Contact Required TC Phone Required
Air Permit Number Required The code is the Facility ID provided in your the Section 114 letter and should be the same as the Facility ID you entered for this facility in the Component 1 Reporting Tool. Source ID-Required Enter the unit ID that you provided for this unit in Component 1 and/or Component 2 of the ICR. Name-Optional The name is optional. The remainder of the Permit/SCC form Optional The remainder of this form, including the SCC section is optional. Question 1, 2, and 3 Optional

Question 4a Required Required If required for your test, you should report the average heat input during the test run (mmBtu/hr); average fuel composition and feed rate during each test run; and average steam output (1000 lb steam/hour) during each test run. If a control device is installed you must also report control device operating or monitoring parameters during each test run (including, as appropriate to the control device, flue gas flow rate, pressure drop, scrubber liquor pH, scrubber liquor flow rate, sorbent type and sorbent injection rate), and process parameters (including, flue gas oxygen content (%), flue gas carbon dioxide content (%), flue gas moisture content (%), flue gas sampling point temperature (Deg F) and pressure (atm), standard temperature (Deg F) and pressure (atm), unit gross electrical output (MWe), unit net electric generation (MWh)). Question 4b Required Required Question 5a Required Required Listed below in Form: Attachments Source/Process Flow Diagram

Question 5b Required Required Required data entry fields for data reported in order of process flow. Add description and provide detailed description in section 5a. Each control device should have a target value, a unit of measure (UOM), and description of what the target value and the UOM represent. These values can be, for example, the guaranteed emission limits or performance guarantee provided by control device vendors. Examples would be NO x removal efficiency (in percent) for post combustion NO xcontrols, PM removal efficiency (in percent) for PM controls, or SO 2 removal efficiency in percent for post combustion SO 2 controls. For example, for an ESP, a user might enter: in UOM (Percent), in Target (99), and in Comments (PM removal Efficiency). Question 6 Required Location of test should be downstream from the last control device. 7a Required Each test should be at least comprised of three runs. 7b Required The units of measure for each method should match the units provided in the instructions included in Component 4. Questions 8-11 Required Questions 12-16 Required Questions 17-19 Optional All Questions Required Setup / Test Plan Module 

### List of Required Data Entry Fields for Data Reported in the ERT

Form: Signatures Permitted State Source ID/Name

Form: Schedule Note: Facility does not have to get test plan approved by the Agency, but ERT requires the test plan to be entered into the pro gram before test results can be entered into the system. Form: Facility/Tester

Form: Permit/SCC

Form: Regulations Form: Process/APCD

Form: Locations/Methods

Form: Methods Cont. Form: Audit/CalibrationsAll Questions Required Source/Process Flow Diagram Alternate Method Request and Approval (Item 8) (optional) EPA Method 1Location Supporting Documentation (Item 9) (optional) Cyclonic Flow Absence Supporting Documentation (Item 10) Pre-Test Meter Boxes/DGMs Calibrations Post-Test Meter Boxes/DGMs Calibrations Nozzles Calibrations Pitots Calibrations Thermocouples Calibrations Sampling Locations Dimensions and Point Locations Run Field Data Sheets Moisture Recovery Lab Data including calibrations and detection level determinations Chain-of-Custody Observer Comments APCD Diagram All Questions Required All Questions for Report Signatures Form Required Form: Attachments Test Data Module

Required (as a part of the test report) Rather than attaching the these items to the ERT, they should be included in the test report submitted to the Refinery ICR website or to the ICR email address.

Test Data Review Module

Test Report Module