### EPA Form 5900-79 OMB No. 2060-0336, Approval Expires 04/30/2012



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

GENERAL INFORMATION AND SUMMARY (GIS)

A. Mailing Address and Contact Information

Facility name ________________________________________________________________

Mailing address: Str eet or P.O. Box ____________________________________________

City ____________________________________ State _______ ZIP ___________-________

Contact person: __________________________ Title ______________________________

Telephone (______) ________ - ___________ Ext. _________

Facsimile (______) ________ - ___________

B. Facility Location

Temporary source? ___Yes ___No Plant site location _____________________________________

__________________________________________________________________________________

City ____________________________ State_____ County________________ EPA Region____

Is the facility located within:

Indian lands? ___YES ___ NO OCS waters? ___YES ___ NO

Non-attainment area? ___ YES ___NO If yes, for what air pollutants? _________

Within 50 miles of affected State? __ YES __ NO If yes, What State(s)? _____

C. Owner

Name ________________________________ Street/P.O. Box _________________________

City _______________________________________ State______ ZIP_________ - ________

Telephone (_____) ______ - __________ Ext_________

D. Operator

Name _______________________________ Street/P.O. Box __________________________

City _______________________________________ State ______ ZIP _________ - _______

Telephone (_____) ______ - __________ Ext_________

### GIS 2

EPA Form 5900-79 E. Application Type

Mark only one permit application type and answer t he supplementary question appropriate for the type

marked.

___Initial Permit ___ Renewal ___ Significant Mod ___ Minor Permit Mod(MPM)

___ Group Processing, MPM ___ Administrative Amendment

For initial permits, when did operations commence? _____ /_____ /_____

For permit renewal, what is the expi ration date of current permit? _____/____/_____

F. Applicable Requirement Summary

Mark all types of applicable requirements that apply.

___ SIP ___ FIP/TIP ___ PSD ___Non-attainment NSR

___ Minor source NSR ___ Section 111 ___ Phase I acid rain ___Phase II acid rain

___ Stratospheric ozone ___ OCS regulations ___ NESHAP ___ Sec. 112(d) MACT

___ Sec. 112(g) MACT ___ Early reduction of HAP ___ Sec 112(j) MACT ___ RMP [Sec.112(r)]

___ Tank Vessel requirements, sec. 183(f)) ___ Section 129 Standards/Requirement

___ Consumer / comm.. products, ' 183(e) ___ NAAQS, increments or visibility (temp. sources)

Has a risk management plan been registered? ___YES ___NO Regulatory agency ____________

Phase II acid rain application submitted? ___YES ___NO If yes, Permitting authority ____________

G. Source-Wide PTE Restrictions and Generic Applicable Requirements

Cite and describe any emissions-limiting requirements and/or facility-wide "generic" applicable requirements.

### GIS 3

EPA Form 5900-79 H. Process Description

List processes, products, and SIC codes for the facility.

Process Products SIC

I. Emission Unit Identification

Assign an emissions unit ID and describe each emissions unit at the facility. Control equipment and/or alternative

operating scenarios associated with emissions units should by listed on a separate line. Applicants may exclude

from this list any insignificant emissions units or activities.

Emissions Unit ID Description of Unit

### GIS 4

EPA Form 5900-79 J. Facility Emissions Summary

Enter potential to emit (PTE) for the facility as a whole for each air pollutant listed below. Enter the name of the

single HAP emitted in the greatest amount and its PTE. For all pollutants stipulations to major source status

may be indicated by entering "major" in the space for PTE. Indicate the total actual emissions for fee purposes

for the facility in the space provided. Applications for permit modifications need not include actual emissions

information.

NOx ___________ tons/yr VOC ___________ tons/yr SO2 ___________ tons/yr

PM-10 ___________ tons/yr CO ___________ tons/yr Lead ___________ tons/yr

Total HAP ___________ tons/yr

Single HAP emitted in the greatest amount ________________________ PTE _______ tons/yr

Total of regulated pollutants (for fee calculation), Sec. F, line 5 of form FEE _____ tons/yr

K. Existing Federally-Enforceable Permits

Permit number(s) _________________ Permit type _____________ Permitting authority __________

Permit number(s) _________________ Permit type _____________ Permitting authority _________

L. Emission Unit(s) Covered by General Permits

Emission unit(s) subject to general permit _______________________________________________

Check one: ___ Application made ___ Coverage granted

General permit identifier ______________________________ Expiration Date ____/____/____

M. Cross-referenced Information

Does this application cross-reference information? ___ YES ___ NO (If yes, see instructions)

INSTRUCTIONS FOLLOW

### GIS 5

EPA Form 5900-79 INSTRUCTIONS FOR GIS,

GENERAL INFORMATION AND SUMMARY

Use this form to provide general and summary information about the part 71 source (facility or plant)

and to indicate the permitting action requested. Submit this form once for each part 71 source.

Several sections of this form ask for information you may not know until you complete other part 71

forms.

Section A - Enter the facility's official or legal name. The contact person should be a person familiar

with the day-to-day operation of the facility, such as a plant site manager or similar individual.

Section B – If different from the mailing address, include the plant site location.

Sections C and D

- If more than one owner or operator, list them on an attachment.

Section E - Mark initial permit issuance if you are applying for the first time. For all types of permit

revisions, applicants must provide a brief narrative description of the changes.

Section F - Indicate the broad categories of applicable requirements that apply to the facility or

any emissions units. Note that acid rain requirements must be included in part 71 permits the

same as other requirements. Also see definition of “applicable requirement” in part 71.

Section G – List emission-limiting requirements that apply to the facility as a whole, such as

restrictions on potential to emit or applicable requirements that apply identically to all emission

units at a facility.

Section H - List, in descending order of priority, the 4-digit standard industrial classification (SIC)

code(s) that best describes your facility in terms of its principal products or processes, and provide

a brief narrative description for each classification. For a listing of SIC codes, see the Standard

Industrial Classification Manual , 1987 edition, prepared by the Executive Office of the President,

Office of Management and Budget, from the Go vernment Printing Office, Washington DC.

Section I

- Assign a unique identifier (unit ID) under the "emissions unit ID" column and provide a

text description for each significant emissions unit at facility. These IDs will be used in other part

71 forms. A "significant emissions unit" is any unit that is not an insignificant emission unit or

activities. Note that unit IDs need only be assigned if they will be referenced in subsequent

portions of the application. You may choose any num bering system you wish to assign unit IDs. If

a unit ID was previously assigned, use the original ID. If the unit is a new unit, assign a unit ID

consistent with the existing units’ IDs.

You may group emissions units, activities, or pieces of equipment together and assign a single

unique unit ID when they are subject to the same applicable requirement(s) and will have the same

monitoring, record keeping, and reporting requirements in the permit.

In addition, assign a unit ID for each alternative operating scenario and each piece of pollution

control equipment. When possible, assign these numbers so as to show with which emissions

units or processes these scenarios or control devices are associated.

Section J - Show the total emissions for the source in terms of PTE for applicability purposes for

each air pollutant listed below and the total actual emissions for fee purposes. Applications for

permit revisions should report PTE after the change for the emissions units affected by the change.

Completion of form PTE is recommended prior to the entry of PTE information in this section.

### GIS 6

EPA Form 5900-79 "NOx" is an abbreviation for nitrogen oxides,

"VOC" is for volatile organic compounds,

"SO2" is for sulfur dioxide,

"PM10" is for particulate matter with an aerody namic diameter of 10 micrometers or less,

"CO" is for carbon monoxide, and

“Lead” is for elemental lead regulated by a NAAQS (“compounds of lead” are HAP).

Also note that each HAP on the list of HAP in section 112(b) of the Act is a separate regulated air

pollutant.

Include fugitive emissions when reporting PTE to the extent that they count toward major source

applicability. All fugitive emissions of HAP count toward major source applicability.

Sources may also stipulate to major source status for the pollutants indicated on the form by

entering "Major" in the space provided for PTE values.

You may use the value for actual emissions from section F, line 5, of form FEE . When totaling

actual emissions for fee purposes, include all emissions, including fugitive emissions, regardless of

whether they count for applicability purposes.

Section L

- If any emissions unit within your facility is applying, has applied, or currently has a

general permit, identify the emissions unit ID and name of the unit, consistent with section I of this

form.

Section M - Attach copies of any cross-referenced doc uments that are not publicly available or

otherwise available to the permitting authority.



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