Appendix B-1 

EIQ Forms 

 
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 1.0 GENERAL PLANT INFORMATION

FIPS COUNTY NO. PLANT NO.

EXT.

STATE ZIP CODE +4

SIC

LATITUDE LONGITUDE UTM COORDINATES

DEGREES

ZONE EASTING (M) NORTHING (M) ACC (M)

MINUTES

SECONDS

EXT.

STATE

PM10 SOX NOX VOC CO LEAD HAPs PM2.5 NH3

LOGGED IN BY DATE

MO 780-1431 (12-09)

ZIP CODE +4

Missouri Department of Natural Resources

Air Pollution Control Program

eiq@dnr.mo.gov

www.dnr.mo.gov/env/apcp/moeis/emissionsreporting.htm

573-751-4817

Jefferson City, MO 65101

1659 E. Elm St.

DATE

Request Confidentiality - see instructions to initiate the confidentiality request.

CONTACT INFORMATION

DATE

CONTACT PERSON NAME CONTACT PERSON TITLE

TITLE PAYMENT DATE

CITY

TOTAL PLANT EMISSIONS FROM FORM 3.0 (TONS PER YEAR)

PARENT COMPANY NAME

OFFICE USE ONLY

PRINT NAME OF AUTHORIZED COMPANY REPRESENTATIVE

CHECK/AUTH. NO.

PRINT NAME OF PERSON COMPLETING FORM

SIGNATURE

PAYMENT AMOUNT

SIGNATURE

FACILITY CONTACT NAME FACILITY CONTACT TITLE FACILITY CONTACT E-MAIL WHERE TO SEND EIQ IN FUTURE (CHECK ONE)

ZIP CODE +4

PRODUCT/PRINCIPAL ACTIVITY

FACILITY MAILING ADDRESS

MAILING ADDRESS

CITY

FACILITY NAME

FACILITY STREET ADDRESS COUNTY NAME

FAX NUMBER WITH AREA CODE

YEAR OF DATA

NUMBER OF EMPLOYEES

FAX NUMBER WITH AREA CODE

CONTACT PERSON E-MAIL COUNTRY

HORIZONTAL DATUM (CHECK ONE)

PHONE NUMBER WITH AREA CODE

NAICS

TITLE

The undersigned hereby certifies that they have personally examined and are familiar with the information and statements contained

herein and further certifies that they believe this information and statements to be true, accurate and complete. The undersigned

certifies that knowingly making a false statement or misrepresenting the facts presented in this document is a violation of state law.

PHONE NUMBER WITH AREA CODE

CITY





	










MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 1.1 PROCESS FLOW DIAGRAM

FIPS COUNTY NO. PLANT NO.

MO 780-1619 (12-09)

FACILITY NAME YEAR OF DATA

and piece of equipment and provide an identification number for all emission units (including fugitive emissions) and air

pollution control equipment. Make sure to use the same identification number throughout the entire EIQ.

Use this page or a separate sheet to provide a Process Flow Diagram per the instructions for Form 1.1 in the Instruction

Packet. Do not forget to include all processes used in your facility. Make sure to label each process
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 1.2 SUMMARY OF EMISSION UNITS AND RELATED PROCESSES

FIPS COUNTY NO. PLANT NO.

Pollutant PM10 SOx NOx VOC CO

CATEGORY 1

HAPs

CATEGORY 2

HAPs

PM2.5 NH3

Threshold (lbs) 876 2,000 2,000 876 2,000 20 200 876 876

Threshold (tons) 0.438 1.0 1.0 0.438 1.0 0.01 0.1 0.438 0.438

EMISSION UNIT NO.

SCC Active Inactive Dismantled

Under

Construction

Insignificant

MO 780-1620 (12-09)

EMISSION UNIT DESCRIPTION

(USE SAME DESCRIPTION ON FORM 2.0)

If all emissions are under the reporting threshold, mark below as "Insignificant", and do not report on Forms 2.0 and 3.0.

If one pollutant exceeds the reporting threshold, mark below as "Active" and report all pollutants on Forms 2.0 and 3.0.

REPORTING THRESHOLD

OPERATING STATUS (CHOOSE ONE)

FACILITY NAME YEAR OF DATA

INSTRUCTIONS
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0 EMISSION UNIT INFORMATION

PLANT NO. YEAR OF DATA

EMISSION UNIT NO.

SEG. NO.

IF YES, COMPLETE FORM 2.0S STACK/VENT INFORMATION

3. OPERATING RATE/SCHEDULE

DEC-FEB (%)

MAR-MAY (%) Heat Content (BTU/Fuel Unit)

HOURS / DAY DAYS / WEEK WEEKS / YR. TOTAL HOURS / YR. JUN-AUG (%) ASH % (INCLUDE IN EF)

SEPT-NOV (%) SULFUR % (INCLUDE IN EF)

1. 2. 3. 4. 5.

AIR

POLLUTANT

SOURCE OF

EMISSION

FACTOR

EMISSION

FACTOR

EMISSION

FACTOR (EF)

CONTROL

STATUS

OVERALL

CONTROL

EFFICIENCY

(% FORMAT)

ACTUAL

EMISSIONS

(TONS/YR)

Instructions:

Choose from the

Source of Emission

Factor List

at lower right

Lbs./unit of throughput

If EF includes control

mark "C",

otherwise "U"

Combination of all

capture and

destruction

efficiencies

If controlled, include

Form 2.0C Control

Device Listing

List Other Worksheets or AP42/Other Reference

1. CEM Include documentation

2. Stack Test Include documentation

3. Mass Balance Include documentation

4. AP-42 Include reference

4F. FIRE or webFIRE

5. Other Include documentation

EC. Engr Calc Include documentation

LS. Landfill Spdsht Include documentation

TK. TANKS Program Supply TANKS output

2.3. VOC Mass Bal Complete Form 2.3

2.4. Liquid Loading Complete Form 2.4

2.7. Haul Road Complete Form 2.7

2.8. Storage Pile Complete Form 2.8

2.T. HAP Worksheet Complete Form 2.T

2.9. Stack Test/CEM Complete Form 2.9

2.0L. Landfill Complete Form 2.0L

MO 780-1621 (12-09)

EMISSION UNIT DESCRIPTION

SOURCE OF EMISSION FACTOR LIST

5. EMISSION CALCULATIONS

PM10

SOX

NOX

VOC

LEAD

1. EMISSION UNIT IDENTIFICATION

CO

4. ANNUAL FUEL CHARACTERISTICS

HAPs

ARE THE EMISSIONS FROM THIS UNIT FUGITIVE? IF FUGITIVE, WHAT PERCENTAGE?

2. EMISSION PROCESS DETAIL

SOURCE CLASSIFICATION CODE (SCC) SCC DESCRIPTION

DO THE EMISSIONS FROM THIS UNIT FLOW THROUGH A STACK OR VENT?

FACILITY NAME FIPS COUNTY NO.

For coal or fuel oil, list details below

ANNUAL THROUGHPUT

PM2.5

NH3

UNITS

Annual Throughput

× Emission Factor

× (1-Overall Control Eff/100)

÷ 2,000

= Actual Emissions (tons)

  

  
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0 PART 70 OPERATING PERMIT EMISSION UNIT INFORMATION

PLANT NO. YEAR OF DATA

EMISSION UNIT NO.

SEG. NO.

3. OPERATING RATE/SCHEDULE

DEC-FEB (%)

MAR-MAY (%) Heat Content (BTU/Fuel Unit)

HOURS / DAY DAYS / WEEK WEEKS / YR TOTAL HOURS / YR JUN-AUG (%) ASH % (INCLUDE IN EF)

SEPT-NOV (%) SULFUR % (INCLUDE IN EF)

1. 2. 3. 4. 5.

AIR

POLLUTANT

SOURCE OF

EMISSION

FACTOR

EMISSION

FACTOR

EMISSION

FACTOR (EF)

CONTROL

STATUS

OVERALL

CONTROL

EFFICIENCY

(% FORMAT)

ACTUAL

EMISSIONS

(TONS/YR)

Instructions:

Choose from the

Source of Emission

Factor List

at lower right

Lbs/unit of throughput

If EF includes control

mark "C",

otherwise "U"

Combination of all

capture and

destruction

efficiencies

If controlled, include

Form 2.0C Control

Device Listing

List Other Worksheets or AP42/Other Reference

1. CEM Include documentation

2. Stack Test Include documentation

3. Mass Balance Include documentation

4. AP-42 Include reference

4F. FIRE or webFIRE

5. Other Include documentation

EC. Engr Calc Include documentation

LS. Landfill Spdsht Include documentation

TK. TANKS Program Supply TANKS output

2.3. VOC Mass Bal Complete Form 2.3

2.4. Liquid Loading Complete Form 2.4

2.7. Haul Road Complete Form 2.7

2.8. Storage Pile Complete Form 2.8

2.T. HAP Worksheet Complete Form 2.T

2.9. Stack Test/CEM Complete Form 2.9

2.0L. Landfill Complete Form 2.0L

MO 780-2087 (12-09)

PM CON *

PM2.5 FIL *

NH3

UNITS

FACILITY NAME FIPS COUNTY NO.

ARE THE EMISSIONS FROM THIS UNIT FUGITIVE? IF FUGITIVE, WHAT PERCENTAGE?

2. EMISSION PROCESS DETAIL

SOURCE CLASSIFICATION CODE (SCC) SCC DESCRIPTION

DO THE EMISSIONS FROM THIS UNIT FLOW THROUGH A STACK OR VENT? IF YES, COMPLETE FORM 2.0S STACK/VENT INFORMATION

4. ANNUAL FUEL CHARACTERISTICS

HAPs

ANNUAL THROUGHPUT For coal or fuel oil, list details below

1. EMISSION UNIT IDENTIFICATION

CO

5. EMISSION CALCULATIONS

PM10 FIL *

SOX

NOX

VOC

LEAD

SOURCE OF EMISSION FACTOR LIST

* If PM CON is reported, PM10 and PM25 entries above are

required and should represent only the filterable PM10 and

filterable PM25.

EMISSION UNIT DESCRIPTION

Annual Throughput

× Emission Factor

× (1-Overall Control Eff/100)

÷ 2,000

= Actual Emissions (tons)

  

  
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0C CONTROL DEVICE INFORMATION

SEG. NO.

PM10 SOX NOX VOC CO LEAD HAP(s) PM2.5 NH3

SEG. NO.

PM10 SOX NOX VOC CO LEAD HAP(s) PM2.5 NH3

SEG. NO.

PM10 SOX NOX VOC CO LEAD HAP(s) PM2.5 NH3

MO 780-1434 (12-09)

AIR POLLUTANT

CAS NUMBER(S) FOR CONTROLLED HAPS

ARE THE EMISSIONS CONTROLLED THROUGH THE STACK/VENT ONLY?

LIST ALL STACK/VENT NUMBERS SHARING THIS CONTROL DEVICE (LISTED ON FORM 2.0S STACK/VENT INFORMATION )

CAPTURE EFFICIENCY (%)

SOURCE OF EFFICIENCY (CODES)

CONTROL DEVICE EFFICIENCY (%)

LIST ALL STACK/VENT NUMBERS SHARING THIS CONTROL DEVICE (LISTED ON FORM 2.0S STACK/VENT INFORMATION )

DEVICE NO.

CAPTURE EFFICIENCY (%)

CONTROL DEVICE EFFICIENCY (%)

AIR POLLUTANT

CONTROL DEVICE DESCRIPTION OPERATING STATUS (CHECK ONE)

SOURCE CLASSIFICATION CODE (SCC)

CAPTURE EFFICIENCY (%)

CONTROL DEVICE EFFICIENCY (%)

SOURCE OF EFFICIENCY (CODES)

CAS NUMBER(S) FOR CONTROLLED HAPS

EMISSION UNIT NO.

FACILITY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

DEVICE NO. DEVICE CODE

ARE THE EMISSIONS CONTROLLED THROUGH THE STACK/VENT ONLY?

ARE THE EMISSIONS CONTROLLED THROUGH THE STACK/VENT ONLY?

AIR POLLUTANT

DEVICE NO. DEVICE CODE

LIST ALL STACK/VENT NUMBERS SHARING THIS CONTROL DEVICE (LISTED ON FORM 2.0S STACK/VENT INFORMATION )

CONTROL DEVICE DESCRIPTION OPERATING STATUS (CHECK ONE)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)

SOURCE OF EFFICIENCY (CODES)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)

CAS NUMBER(S) FOR CONTROLLED HAPS

CONTROL DEVICE DESCRIPTION OPERATING STATUS (CHECK ONE)

DEVICE CODE

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0C PART 70 OPERATING PERMIT CONTROL DEVICE INFORMATION

SEG. NO.

PM10 FIL SOX NOX VOC CO LEAD HAP(s) PM2.5 FIL NH3 PM CON

SEG. NO.

PM10 FIL SOX NOX VOC CO LEAD HAP(s) PM2.5 FIL NH3 PM CON

SEG. NO.

PM10 FIL SOX NOX VOC CO LEAD HAP(s) PM2.5 FIL NH3 PM CON

MO 780-2088 (12-09)

CONTROL DEVICE DESCRIPTION OPERATING STATUS (CHECK ONE)

SOURCE CLASSIFICATION CODE (SCC) DEVICE NO.

YEAR OF DATA

CAPTURE EFFICIENCY (%)

PLANT NO.

EMISSION UNIT NO.

FACILITY NAME FIPS COUNTY NO.

DEVICE CODE

ARE THE EMISSIONS CONTROLLED THROUGH THE STACK/VENT ONLY?

AIR POLLUTANT

CAPTURE EFFICIENCY (%)

LIST ALL STACK/VENT NUMBERS SHARING THIS CONTROL DEVICE (LISTED ON FORM 2.0S STACK/VENT INFORMATION )

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) DEVICE CODE

CONTROL DEVICE EFFICIENCY (%)

SOURCE OF EFFICIENCY (CODES)

CAS NUMBER(S) FOR CONTROLLED HAPS

DEVICE CODE

AIR POLLUTANT

CONTROL DEVICE EFFICIENCY (%)

SOURCE OF EFFICIENCY (CODES)

CAS NUMBER(S) FOR CONTROLLED HAPS

SOURCE CLASSIFICATION CODE (SCC) DEVICE NO.

DEVICE NO.

LIST ALL STACK/VENT NUMBERS SHARING THIS CONTROL DEVICE (LISTED ON FORM 2.0S STACK/VENT INFORMATION )

CONTROL DEVICE DESCRIPTION OPERATING STATUS (CHECK ONE)

ARE THE EMISSIONS CONTROLLED THROUGH THE STACK/VENT ONLY?

EMISSION UNIT NO.

CAS NUMBER(S) FOR CONTROLLED HAPS

ARE THE EMISSIONS CONTROLLED THROUGH THE STACK/VENT ONLY?

CAPTURE EFFICIENCY (%)

SOURCE OF EFFICIENCY (CODES)

CONTROL DEVICE EFFICIENCY (%)

LIST ALL STACK/VENT NUMBERS SHARING THIS CONTROL DEVICE (LISTED ON FORM 2.0S STACK/VENT INFORMATION )

CONTROL DEVICE DESCRIPTION

AIR POLLUTANT

OPERATING STATUS (CHECK ONE)

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0K CHARCOAL KILN INFORMATION

LAST YEAR SINCE 1991

LAST YEAR SINCE 1991

LAST YEAR SINCE 1991

LAST YEAR SINCE 1991

LAST YEAR SINCE 1991

MO 780-1530 (12-09)

PRESENT CONDITION

KILN ID NO. YEAR KILN BEGAN OPERATING IF NO PRODUCTION, LAST YEAR OF

PRODUCTION

AFTERBURNER OR

RECOVERY

SYSTEM

NUMBER OF HOURS REQUIRED TO

PRODUCE ONE BATCH

MAXIMUM TONS PRODUCED IN ONE MAX HOURLY DESIGN RATE DOLLARS SPENT ON RENOVATION

BATCH

KILN ID NO. YEAR KILN BEGAN OPERATING TONS PRODUCED THIS YEAR IF NO PRODUCTION, LAST YEAR OF

PRODUCTION

AFTERBURNER OR

RECOVERY

SYSTEM

PRESENT CONDITION

MAXIMUM TONS PRODUCED IN ONE

BATCH

NUMBER OF HOURS REQUIRED TO

PRODUCE ONE BATCH

MAX HOURLY DESIGN RATE DOLLARS SPENT ON RENOVATION

KILN ID NO. YEAR KILN BEGAN OPERATING TONS PRODUCED THIS YEAR IF NO PRODUCTION, LAST YEAR OF

PRODUCTION

AFTERBURNER OR

RECOVERY

SYSTEM

DOLLARS SPENT ON RENOVATION

AFTERBURNER OR

RECOVERY

SYSTEM

MAXIMUM TONS PRODUCED IN ONE MAX HOURLY DESIGN RATE DOLLARS SPENT ON RENOVATION

BATCH

KILN ID NO. YEAR KILN BEGAN OPERATING

PRESENT CONDITION

NUMBER OF HOURS REQUIRED TO

PRODUCE ONE BATCH

MAXIMUM TONS PRODUCED IN ONE

BATCH

TONS PRODUCED THIS YEAR

NUMBER OF HOURS REQUIRED TO

PRODUCE ONE BATCH

MAX HOURLY DESIGN RATE

PRESENT CONDITION

TONS PRODUCED THIS YEAR IF NO PRODUCTION, LAST YEAR OF

PRODUCTION

AFTERBURNER OR

RECOVERY

SYSTEM

IF NO PRODUCTION, LAST YEAR OF

PRODUCTION

DOLLARS SPENT ON RENOVATION

PRESENT CONDITION

KILN ID NO. YEAR KILN BEGAN OPERATING TONS PRODUCED THIS YEAR

MAXIMUM TONS PRODUCED IN ONE

BATCH

NUMBER OF HOURS REQUIRED TO

PRODUCE ONE BATCH

MAX HOURLY DESIGN RATE

COMPLETE ONE OF THE FOLLOWING SECTIONS FOR EACH CHARCOAL KILN/CONCRETE PAD

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) SEG. NO.

FACILITY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

 



 

 



 



 




MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0L LANDFILL WORKSHEET

CELL(B15)

CELL(B13)

CELL(B24)

CELL(B14)

CELL(B16) CELL(B18)

CELL(G11) CELL(H11)

CELL(N35) CELL(I50)

CELL(G88) CELL(G51)

CELL(I88) CELL(I51)

CELL(K88) CELL(K51)

CELL(L31) CELL(L32)

CELL(N31) CELL(N33)

MO 780-1583 (12-09)

SO2 EMISSIONS (LB./YR.)

Default values are 100 m^3/Mg for L (Methane generation rate potential) and 0.04/yr for k (Methane generation rate constant).

ACRES OF LANDFILL

Default capture efficiency is 75 percent.

Documentation must be supplied for

other values.

CELL(B17)

NMOC (HAP ONLY) COLLECTED, UNCONTROLLED (LB./YR.)

EMISSION UNIT NO.

TIME SINCE INITIAL REFUSE PLACEMENT (YRS.) t=

TIME SINCE CLOSURE (YRS.) c=

LANDFILL INFORMATION

Used DNR spreadsheet created with

Microsoft

® Excel®

(attach copies)

SOURCE CLASSIFICATION CODE (SCC)

FACILITY NAME

METHANE GENERATION RATE (QCH4) (m3/YR.) METHANE GENERATION RATE (MMCF)

TYPE OF LANDFILL (CHECK ONE)

IF CLOSED, DATE OF LAST WASTE ACCEPTED

SEG. NO.

GAS SENT OFF-SITE (MMCF)

CALCULATION OF EMISSIONS

Used EPA's software (LANDGEM)

(attach summary)

TYPE OF CONTROL (CHECK ONE)

CAPTURE EFFICIENCY

AVERAGE ANNUAL REFUSE ACCEPTANCE RATE (Mg/YR.) R= MASS OF SOLID WASTE IN THE LANDFILL (Mg)

DESTRUCTION EFFICIENCY (%) LANDFILL DESIGN CAPACITY (CUBIC METERS)

Report fugitive emissions and controlled emissions on separate Forms 2.0.

Fugitive emissions use SCC 50100402, throughput units of acres.

NMOC (VOC) COLLECTED, UNCONTROLLED (LB./YR.)

NMOC (VOC) FUGITIVE EMISSIONS (LB./YR.)

HCl EMISSIONS (LB./YR.)

NMOC (HAP ONLY) FUGITIVE EMISSIONS (LB./YR.)

VOC TO CONTROL EMISSION FACTOR (LB./MMCF) HAP TO CONTROL EMISSION FACTOR (LB./MMCF)

Waste gas flares use SCC 50100410, throughput unit of MMCF burned.

For SCCs for other controls, contact your regulatory agency.

CALCULATION OF EMISSION FACTORS

NMOC (VOC) EMISSIONS FROM CONTROL (LB./YR.) NMOC (HAP ONLY) EMISSIONS FROM CONTROL (LB./YR.)

VOC FUGITIVE EMISSION FACTOR (LB./ACRE) HAP FUGITIVE EMISSION FACTOR (LB./ACRE)

FIPS COUNTY NO. PLANT NO. YEAR OF DATA

#

$%








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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0P PORTABLE PLANT INFORMATION

PLANT NO. PROJECT NO.

FIRST DATE AT SITE LAST DATE AT SITE

HOURS DAYS WEEKS

Latitude Longitude

Degrees

EASTING (M) NORTHING (M) ACC (M)

Minutes

Seconds

PLANT NO. PROJECT NO.

FIRST DATE AT SITE LAST DATE AT SITE

HOURS DAYS WEEKS

Latitude Longitude

Degrees

EASTING (M) NORTHING (M) ACC (M)

Minutes

Seconds

PLANT NO. PROJECT NO.

FIRST DATE AT SITE LAST DATE AT SITE

HOURS DAYS WEEKS

Latitude Longitude

Degrees

EASTING (M) NORTHING (M) ACC (M)

Minutes

Seconds

MO 780-1433 (12-09)

UTM Coordinates

HORIZONTAL DATUM (CHECK ONE)

UTM Coordinates

PHONE NUMBER WITH AREA CODE

PORTABLE EQUIPMENT OPERATING SITE INFORMATION

COMPANY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

PORTABLE EQUIPMENT OPERATING SITE INFORMATION

TYPE OF INSTALLATION/UNIT

SITE OR LOCATION NAME PERCENT OF TOTAL THROUGHPUT AT SITE (%)

FIPS COUNTY NO.

SITE OR LOCATION NAME PERCENT OF TOTAL THROUGHPUT AT SITE (%)

ADDRESS

HORIZONTAL DATUM (CHECK ONE)

Period of Operation

CITY ZIP CODE +4 PHONE NUMBER WITH AREA CODE

PORTABLE EQUIPMENT OPERATING SITE INFORMATION

FIPS COUNTY NO. TYPE OF INSTALLATION/UNIT

ADDRESS

Period of Operation

CITY ZIP CODE +4

UTM Coordinates

HORIZONTAL DATUM (CHECK ONE)

FIPS COUNTY NO. TYPE OF INSTALLATION/UNIT

SITE OR LOCATION NAME PERCENT OF TOTAL THROUGHPUT AT SITE (%)

PHONE NUMBER WITH AREA CODE

ADDRESS

Period of Operation

CITY ZIP CODE +4

 

	




	




	





MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0S STACK/VENT INFORMATION

PLANT NO.

SEG. NO.

HEIGHT (FT.) DIAMETER (FT.)

SEG. NO.

HEIGHT (FT.) DIAMETER (FT.)

SEG. NO.

HEIGHT (FT.) DIAMETER (FT.)

SEG. NO.

HEIGHT (FT.) DIAMETER (FT.)

SEG. NO.

HEIGHT (FT.) DIAMETER (FT.)

SEG. NO.

HEIGHT (FT.) DIAMETER (FT.)

MO 780-1435 (12-09)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)

TEMPERATURE (F) VELOCITY (FT./MIN.)

STACK/VENT OPERATING STATUS (CHECK ONE)

STACK/VENT NO. % OF EMISSIONS RELEASED

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)

STACK/VENT DESCRIPTION

SOURCE CLASSIFICATION CODE (SCC)

FLOW RATE (CU FT./MIN.) LIST OTHER POINTS SHARING THIS

STACK/VENT

FOR A NON-CIRCULAR STACK:

DIAMETER = (1.128A)^1/2

(A=CROSS-SECTIONAL AREA IN SQ FEET)

FOR A NON-CIRCULAR STACK:

DIAMETER = (1.128A)^1/2

(A=CROSS-SECTIONAL AREA IN SQ FEET)

LIST OTHER POINTS SHARING THIS

STACK/VENT

FLOW RATE (CU FT./MIN.)

FOR A NON-CIRCULAR STACK:

DIAMETER = (1.128A)^1/2

(A=CROSS-SECTIONAL AREA IN SQ FEET)

STACK/VENT NO. STACK/VENT DESCRIPTION % OF EMISSIONS RELEASED

FACILITY NAME FIPS COUNTY NO. YEAR OF DATA

SOURCE CLASSIFICATION CODE (SCC)

TEMPERATURE (F) VELOCITY (FT./MIN.)

EMISSION UNIT NO.

STACK/VENT OPERATING STATUS (CHECK ONE)

STACK/VENT OPERATING STATUS (CHECK ONE)

TEMPERATURE (F) VELOCITY (FT./MIN.) FLOW RATE (CU FT./MIN.) LIST OTHER POINTS SHARING THIS

STACK/VENT

STACK/VENT NO. STACK/VENT DESCRIPTION % OF EMISSIONS RELEASED

EMISSION UNIT NO.

FOR A NON-CIRCULAR STACK:

DIAMETER = (1.128A)^1/2

(A=CROSS-SECTIONAL AREA IN SQ FEET)

STACK/VENT NO. STACK/VENT DESCRIPTION % OF EMISSIONS RELEASED

FOR A NON-CIRCULAR STACK:

DIAMETER = (1.128A)^1/2

(A=CROSS-SECTIONAL AREA IN SQ FEET)

STACK/VENT OPERATING STATUS (CHECK ONE)

TEMPERATURE (F) VELOCITY (FT./MIN.) FLOW RATE (CU FT./MIN.) LIST OTHER POINTS SHARING THIS

STACK/VENT

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)

STACK/VENT NO. STACK/VENT DESCRIPTION % OF EMISSIONS RELEASED

STACK/VENT OPERATING STATUS (CHECK ONE)

TEMPERATURE (F) VELOCITY (FT./MIN.) FLOW RATE (CU FT./MIN.) LIST OTHER POINTS SHARING THIS

STACK/VENT

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) FOR A NON-CIRCULAR STACK:

DIAMETER = (1.128A)^1/2

(A=CROSS-SECTIONAL AREA IN SQ FEET)

STACK/VENT NO. STACK/VENT DESCRIPTION % OF EMISSIONS RELEASED

STACK/VENT OPERATING STATUS (CHECK ONE)

TEMPERATURE (F) VELOCITY (FT./MIN.) FLOW RATE (CU FT./MIN.) LIST OTHER POINTS SHARING THIS

STACK/VENT



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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.0Z OZONE SEASON INFORMATION - EMISSIONS STATEMENT

SEG. NO.

SEG. NO.

SEG. NO.

MO 780-1452 (12-09)

FACILITY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

OPERATING RATE/SCHEDULE (DURING PEAK OZONE SEASON ONLY)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) DAILY THROUGHPUT UNITS

DAYS/WEEK WEEKS OF OPERATION START TIME ON TYPICAL DAY END TIME ON TYPICAL DAY

EMISSIONS CALCULATIONS

Air Pollutant Emission Factor Control Efficiency (%) Actual Emissions (lbs./day)

VOC

NOX

CO

OPERATING RATE/SCHEDULE (DURING PEAK OZONE SEASON ONLY)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) DAILY THROUGHPUT UNITS

DAYS/WEEK WEEKS OF OPERATION START TIME ON TYPICAL DAY END TIME ON TYPICAL DAY

EMISSIONS CALCULATIONS

Air Pollutant Emission Factor Control Efficiency (%) Actual Emissions (lbs./day)

VOC

NOX

CO

OPERATING RATE/SCHEDULE (DURING PEAK OZONE SEASON ONLY)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) DAILY THROUGHPUT UNITS

DAYS/WEEK WEEKS OF OPERATION START TIME ON TYPICAL DAY END TIME ON TYPICAL DAY

EMISSIONS CALCULATIONS

Air Pollutant Emission Factor Control Efficiency (%) Actual Emissions (lbs./day)

VOC

NOX

CO
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.1 FUEL COMBUSTION WORKSHEET

YEAR OF DATA

SEG. NO.

YEAR

PUT IN

SERVICE

MO 780-1436 (12-09)

3. CALCULATION OF MAXIMUM HOURLY DESIGN RATE

TOTAL HEAT CONTENT

(BTU/FUEL UNIT)

MAXIMUM HOURLY DESIGN RATE

(FUEL UNIT/HR.)

Maximum Design Rate (mmbtu/hr.) × 1,000,000 (btu/mmbtu)

Heat Content (btu/fuel unit)

COAL FIRING

CODE LIST

1. TANGENTIAL

2. OPPOSED

3. FRONT

4. DRY/WET BOTTOM

OTHER (SPECIFY) Sum of total maximum hourly design rates

EQUIPMENT DESCRIPTION

1. COMBUSTION EQUIPMENT INFORMATION

2. FUEL INFORMATION (CHECK ONLY ONE)

LIQUID FUELS OTHER

COMBUSTION EQUIPMENT USE (CHECK ONE)

COMBUSTION EQUIPMENT CATEGORY - COAL USE ONLY (CHECK ONE)

GASEOUS FUELS SOLID FUELS

MAXIMUM DESIGN

RATE

(MILLION BTU/HR.)

COAL FIRING

CODE NO.

(CODE LIST AT LEFT)

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)

FACILITY NAME FIPS COUNTY NO. PLANT NO.

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.2 INCINERATOR WORKSHEET

SOURCE CLASSIFICATION CODE (SCC)

SERIAL NUMBER

UNITS

LBS./YR.

TONS/YR.

MO 780-1438 (12-09)

EMISSION UNIT NO.

FACILITY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

INCINERATOR USE (CHECK ONE):

EQUIPMENT TYPE (CHECK APPROPRIATE BOXES):

1. EQUIPMENT INFORMATION

Enter the total annual throughput (TONS/YR.) into Section 3 on Form 2.0.

NUMBER OF CHAMBERS NOT INCLUDING STACK SECONDARY CHAMBER TEMPERATURE (F)

2. WASTE INFORMATION AND THROUGHPUTS

Total annual throughput =

Total annual throughput (TONS/YR.) = {Total annual throughput (LBS./YR.)} / 2,000

PROCESS WASTE TYPES HEAT CONTENT (BTU/UNITS)

MAXIMUM HOURLY DESIGN RATE

SCC UNITS SEG. NO.

UNITS/HR. MAKE / MODEL

ANNUAL THROUGHPUT

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.3 VOC PROCESS MASS-BALANCE WORKSHEET

PLANT NO. YEAR OF DATA

[A] [B] [C] [D] [E]

APPLICATION

METHOD

ANNUAL

THROUGHPUT

(ton/yr. or gal./yr.)

MAXIMUM %

BY WT. OF

VOC IN

MATERIAL

DENSITY

(LBS./UNIT)

IF (A) IN TONS,

(C)=2,000

LBS. OF

VOC PER

UNIT

(B) × (C) = (D)

VOC (LBS./YR.)

(A) × (D) = (E)

[F] TOTAL ANNUAL

THROUGHPUT

[G] TOTAL VOC (LBS./YR.)

[H] LBS. OF VOC

RECOVERED

[I] LBS. OF VOC EMITTED

PRIOR TO CONTROL

[J] EMISSION FACTOR IN

LBS./UNIT

MO 780-1440 (12-09)

×

% VOC CONTENT OF WASTE

4. CALCULATION OF EMISSION FACTOR

3. CALCULATION OF POUNDS OF VOC EMITTED PRIOR TO CONTROL EQUIPMENT

[G] - [H] = [I]

[Total lbs. of VOC] - [lbs. of VOC recovered] =

Enter the total annual throughput value [F] into

Section [3], Annual Throughput on Form 2.0

2. CALCULATION OF POUNDS OF VOC RECOVERED

=

AMOUNT OF MATERIAL SHIPPED AS HAZARDOUS WASTE

(LBS./YR.)

INSTRUCTIONS

1. TOTAL ANNUAL THROUGHPUT AND TOTAL POUNDS OF VOC

FACILITY NAME FIPS COUNTY NO.

If your facility already calculates your VOC or HAP emissions and emission factor directly through a spreadsheet or engineering

calculation, this form is optional as long as you supply your supporting documentation. This form is designed for annual throughputs

measured in gallons or tons only. If you use another unit of measure, supply documentation of how you calculated total emissions

and an emission factor. Maintain copies of the Material Safety Data Sheet for each material listed and hazardous waste shipment

reports for on-demand requests.

EMISSION UNIT NO. SCC SEG. NO.

[lbs of VOC emitted prior to control equipment] / [Total annual throughput] =

[I] / [F] = [J] Enter [J] on

Form 2.0 as

VOC EF

MATERIAL TYPE
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.4 VOLATILE ORGANIC LIQUID LOADING WORKSHEET

YEAR OF DATA

MO 780-1625 (12-09)

CONTROL EFFICIENCY (%)

BULK LIQUID TYPE

Remember when calculating emissions, use a separate Form 2.0, Emission Unit Information , for each type of

liquid loaded in the tank during the year.

Use the same unit number but with the Source Classification Code that corresponds to the different liquid type.

Enter the Loading Loss Emission Factor from Section 3 into the VOC box of Section 5, Column 2 on Form 2.0

Enter the Annual Throughput of Liquid from Section 1, expressed in thousands of gallons, into Section 3 on Form 2.0.

Enter the Control Efficiency (%) from Section 1 (above) into Section 5, Column 4 on Form 2.0.

NOTE

EMISSION UNIT NO.

1. LOADING INFORMATION

SATURATION FACTOR

ANNUAL THROUGHPUT OF LIQUID (1,000 GALLONS) CONTROL DEVICE TYPE

TYPE OF LOADING (CHECK ONE)

TRUE VAPOR PRESSURE OF BULK LIQUID (PSIA)

SOURCE CLASSIFICATION CODE (SCC) SEG. NO.

Note: This form is used to calculate emissions from loading organic liquids into tank trucks, rail tank cars and barges.

FACILITY NAME FIPS COUNTY NO. PLANT NO.

MOLECULAR WEIGHT OF MATERIAL LOADED [LB. / (LB./MOLE)]

2. CHEMICAL INFORMATION

TEMPERATURE OF LIQUID (DEGREES RANKINE) = DEGREES FAHRENHEIT + 460 DEGREES FAHRENHEIT

LOADING LOSS EMISSION FACTOR =

lbs. per 1,000 gallons

LOADING LOSS EMISSION FACTOR UNITS

12.46 x (Molecular Weight) x (True vapor pressure) x (Saturation) / (Temperature in Degrees Rankine)

3. LOADING LOSS EMISSION FACTOR CALCULATION



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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.5L GENERAL LIQUID STORAGE TANK INFORMATION

FIPS COUNTY NO.

TANK ID SEG. NO. DIAMETER (FT.) HEIGHT (FT.) LENGTH (FT.)

TANK ID SEG. NO. DIAMETER (FT.) HEIGHT (FT.) LENGTH (FT.)

TANK ID SEG. NO. DIAMETER (FT.) HEIGHT (FT.) LENGTH (FT.)

TANK ID SEG. NO. DIAMETER (FT.) HEIGHT (FT.) LENGTH (FT.)

TANK ID SEG. NO. DIAMETER (FT.) HEIGHT (FT.) LENGTH (FT.)

TANK ID SEG. NO. DIAMETER (FT.) HEIGHT (FT.) LENGTH (FT.)

MO 780-1444 (12-09)

CAS NUMBER CHEMICAL CHOOSE TYPE OF TANK (CHECK ONE)

CAPACITY (IN THOUSANDS OF GALLONS) THROUGHPUT (IN THOUSANDS OF GALLONS) TANKS PROGRAM USED?

EMISSION UNIT NO. SCC (BREATHING OR WORKING)

CAS NUMBER CHEMICAL CHOOSE TYPE OF TANK (CHECK ONE)

CAPACITY (IN THOUSANDS OF GALLONS) THROUGHPUT (IN THOUSANDS OF GALLONS) TANKS PROGRAM USED?

EMISSION UNIT NO. SCC (BREATHING OR WORKING)

CAS NUMBER CHEMICAL CHOOSE TYPE OF TANK (CHECK ONE)

CAPACITY (IN THOUSANDS OF GALLONS) THROUGHPUT (IN THOUSANDS OF GALLONS) TANKS PROGRAM USED?

EMISSION UNIT NO. SCC (BREATHING OR WORKING)

CAS NUMBER CHEMICAL CHOOSE TYPE OF TANK (CHECK ONE)

CAPACITY (IN THOUSANDS OF GALLONS) THROUGHPUT (IN THOUSANDS OF GALLONS) TANKS PROGRAM USED?

EMISSION UNIT NO. SCC (BREATHING OR WORKING)

CAS NUMBER CHEMICAL CHOOSE TYPE OF TANK (CHECK ONE)

CAPACITY (IN THOUSANDS OF GALLONS) THROUGHPUT (IN THOUSANDS OF GALLONS) TANKS PROGRAM USED?

EMISSION UNIT NO. SCC (BREATHING OR WORKING)

CAPACITY (IN THOUSANDS OF GALLONS) THROUGHPUT (IN THOUSANDS OF GALLONS) TANKS PROGRAM USED?

EMISSION UNIT NO. SCC (BREATHING OR WORKING)

FACILITY NAME PLANT NO. YEAR OF DATA

CAS NUMBER CHEMICAL CHOOSE TYPE OF TANK (CHECK ONE)

  

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.7 HAUL ROAD FUGITIVE EMISSIONS WORKSHEET

PLANT NO.

SEG. NO. Control

Efficiency

95%

90%

90%

90%

50%

0%

MO 780-1445 (12-09)

If the haul road parameters are the same as last year and the updated emission factor equation is used (AP-42,

Section 13.2.2, Unpaved Roads , Nov. 2006), enter the current annual VMT as the throughput on Form 2.0.

SILT CONTENT (%) (DEFAULT = 8.3%) SURFACE MATERIAL OF ROAD

This worksheet

is optional

LENGTH OF ROAD (MILES): IF ONE-WAY, DIVIDE BY 2

Do not calculate a separate emission factor for each vehicle class. Use the weighted average for the entire fleet traveling the haul

road to calculate the emission factors.

If the sum of all Vehicle Miles Traveled, or VMT, at the facility is less than 100, this form is not necessary and the

emission unit should be marked as insignificant on Form 1.2.

1. HAUL ROAD INFORMATION

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) Type of Dust Control

(check one)

UNLOADED TRUCK WEIGHT (TONS) — WEIGHTED AVERAGE FOR FLEET

2. HAUL TRUCK INFORMATION

DAYS OF RAIN WITH AT LEAST 0.01" PER YEAR (DEFAULT = 105)

TYPE OF MATERIALS HAULED ANNUAL AMOUNT HAULED (TONS)

3. MATERIAL HAULED

AVERAGE WEIGHT OF MATERIAL PER LOAD (TONS) AVERAGE LOADED WEIGHT (TONS) — WEIGHTED AVERAGE FOR FLEET

MAKE/MODEL

PM2.5 Emission Factor

PM10 Emission Factor

PM2.5 EMISSION FACTOR

PM10 EMISSION FACTOR

5. CALCULATION OF HAUL ROAD UNCONTROLLED EMISSION FACTOR

4. CALCULATION OF ANNUAL VEHICLES MILES TRAVELED

ANNUAL VMT

(Average weight of material per load)

2 × (Length of road) × (Annual amount hauled)

Annual VMT =

INSTRUCTIONS

FACILITY NAME FIPS COUNTY NO. YEAR OF DATA

0.15 ×

Silt Content %

12

0.9 Unloaded truck weight + 0.45

Loaded truck weight (tons)

× ×

6

365 - Days of Rain

365

1.5 ×

Silt Content %

12

0.9

0.45

× ×

6

365 - Days of Rain

365

Unloaded truck weight +

Loaded truck weight (tons)


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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.8 STORAGE PILE WORKSHEET

PLANT NO.

SEG. NO.

ACTIVITY

WIND EROSION

(DEFAULT = 0.7%)

(DEFAULT = 1.6%)

(DEFAULT = 32%)

(DEFAULT = 1.0)

MO 780-1446 (12-09)

CALCULATION

0.85 x (Silt content % / 1.5) x (Storage duration (Days)) x (Dry days per year / 235) x

(% of time wind >12 MPH /15)

[3-A-1] Load In - Load Out Component + [3-A-2] Vehicle Activity Component

0.05 x (Silt content % / 1.5) x (Dry days per year / 235) x Vehicle Activity Factor

0.0032 x .35 x (Mean wind speed / 5) ^1.3 / (Moisture content % / 2) ^1.4

(DEFAULT = 260 DAYS)

If you use a Source Classification Code and emission factor from the list in the instructions for this form, make sure to complete

Section 1, Storage Pile Information for each storage pile.

[3-B]

Wind Erosion PM10

Emission Factor

(lb./acre-yr.)

[3-A-3]

Activity PM10

Emission Factor

(lb./ton)

[3-A-2]

Vehicle Activity Component

(lb./ton)

[3-A-1]

Load In - Load Out

Component

(lb./ton)

FORMULA RESULT

DRY DAYS PER YEAR

MEAN WIND SPEED (MPH) % OF TIME WIND > 12 MPH

VEHICLE ACTIVITY FACTOR

(DEFAULT = 10 MPH)

RAW MATERIAL UNLOADING METHOD

(CHECK ONE):

RAW MATERIAL LOADING METHOD

(CHECK ONE):

ANNUAL AMOUNT STORED (TONS)

STORAGE DURATION (DAYS)

SILT CONTENT(%)

FACILITY NAME FIPS COUNTY NO.

AREA OF STORAGE PILE (ACRES)

SOURCE CLASSIFICATION CODE (SCC)

MOISTURE CONTENT (%)

YEAR OF DATA

1. STORAGE PILE INFORMATION

NOTE

4. STORAGE PILE EMISSION FACTOR CALCULATIONS

2. OTHER FACTORS AFFECTING EMISSION RATES

TYPE OF MATERIAL STORED

EMISSION UNIT NO.

MAXIMUM HOURLY AMOUNT STORED (TONS)

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 2.9 STACK TEST/CONTINUOUS EMISSIONS MONITOR WORKSHEET

MO 780-1447 (12-09)

FACILITY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

Note: Use a separate worksheet

for each pollutant tested.

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC) SEG. NO.

TYPE POLLUTANT TESTED CAS NUMBER

EPA METHOD(S) USED

TESTING FIRM ADDRESS

TESTING FIRM NAME

CITY

PERCENT MONITOR DOWN TIME

RESULTS OF CALIBRATION

UNITS

LBS./HR.

4. EMISSION FACTOR CALCULATION

UNITS/HR.

NAME OF OBSERVER(S)

LATEST CALIBRATION OF TESTING EQUIPMENT

AGENCY OBSERVING TEST (CHECK ONE)

TEST TECHNIQUE (CHECK ONE)

PRODUCTION RATE

STACK NO.

TEST DATE(S) RESULTS COMPLIANCE

2. STACK TEST INFORMATION

1. EMISSION SOURCE INFORMATION

LIMITATIONS ON EMISSIONS, PRODUCTION OR OPERATING TIME (IF ANY)

TYPE OF CONTROL DEVICE

EQUIPMENT MAKE/MODEL

STATE

FLOW RATE OF STACK

MONITOR AVERAGING PERIOD

CONCENTRATION OF POLLUTANT UNITS

LATEST CALIBRATION OF MONITOR

3. CONTINUOUS EMISSION MONITORING INFORMATION

ZIP CODE + 4

Enter the emission factor into the appropriate box in Section 5, Column 3 on Form 2.0.

If applicable, enter the control device type and control efficiency (%) in Section 5 on Form 2.0.

EMISSION FACTOR

EMISSION RATE

Note: Documentation should include summary

page information from the test data to verify

the emission and production rate.

UNITS

UNITS

[{EMISSION RATE} / {PRODUCTION RATE}]

EMISSION FACTOR =

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MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQFORM 2.T HAZARDOUS AIR POLLUTANT WORKSHEET

1. 2. 3. 4. 5. 6. 7. 8. 

HAP CHEMICAL CAS NUMBER

AMOUNT USED OR

HANDLED

(LBS./YR.)

UNCONTROLLED

AMOUNT EMITTED

(LBS./YR.)

UNCONTROLLED

EMISSIONS REPORTED

AS VOC OR PM10

(LBS./YR.)

UNCONTROLLED

EMISSIONS REPORTED

AS HAPs (LBS./YR.)

HAP CONTROL

DEVICE(S)

CONTROL

EFFICIENCY

(%)

SUM (LBS./YR.) SUM (LBS./YR.) 

11. HAP EMISSIONFACTOR

MO 780-1448 (12-09)

Use this form to report any Hazardous Air Pollutant, or HAP, which is emitted in any amount greater than the chemical reporting levels per eac

for this form provide a list of the HAPs regulated under the Clean Air Act. The amount emitted (Column 4) should be reported before control e

Provide documentation (other worksheets, etc.) if the amount in Column 3 does not equal the amount in Column 4. The HAP reporting levels Category 1 HAPs - sum of 20 pounds per year; All other HAPs - sum of 200 pounds per year.

HAP Emission Totals =

Enter the HAP emission factor for all chemicals that are not reported as VOCs or PM10 from Block 11 above as the HAP Emission Facto

Uncontrolled HAP Emission Factor = Sum of uncontrolled emissions reported as HAPs (Column 6 Total)/Annual Throughput (Form 2.0)

FACILITY NAME FIPS COUNTY NO.

EMISSION UNIT NO. SOURCE CLASSIFICATION CODE (SCC)
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 3.0 EMISSIONS FEE CALCULATION

PM10 SOX NOX VOC CO LEAD HAPs PM2.5 NH3

PM10 SOX NOX VOC CO LEAD HAPs PM2.5 NH3

NO FEES

FOR CO

NO FEES

FOR

PM2.5

NO FEES

FOR

NH3

$

MO 780-1509 (12-09)

3. CHARGEABLE EMISSIONS (Maximum 4,000 Tons/Yr. cap per pollutant)

Total

Copy the actual emissions from section 2 to the appropriate box(es) in the Total Plant Emissions Section of

Form 1.0 General Plant Information .

Note: Fill out the lower portion of this form one time only.

Total

1.

SCC AIR POLLUTANT

EMISSION UNIT NO.

2. ACTUAL EMISSIONS (Use the sum of all page totals for each pollutant for actual emission figures below.)

Use one row to list the emissions from one emission unit. Sum the emissions in the page total box at the

bottom of the column. If more than one page is needed, use the first row of the duplicated page to list the

page totals from this page. Express figures in tons per year and round to two decimal places.

Multiply the sum of chargeable emissions as calculated in section 4 by $40 and enter

this amount in section 5. The minimum fee is $40.

Tons/Yr.

PAGE TOTALS

4. SUM OF CHARGEABLE EMISSIONS SUBJECT TO FEES

5. TOTAL ANNUAL EMISSIONS FEE

Round chargeable emissions to the nearest whole ton. The minimum emission

tonnage is one ton, and the maximum is 12,000 tons per year.

CHECK NUMBER AMOUNT REMITTED IN CALENDAR YEAR OF RECORD

6. ANNUAL EMISSIONS FEE REMITTED TO THE CITY OF KANSAS CITY OR ST. LOUIS COUNTY LOCAL AIR AGENCY

9. SEND THE COMPLETED QUESTIONNAIRE AND ANY SUPPORTING DOCUMENTATION TO THE AGENCY LISTED AT THE

BOTTOM OF FORM 1.0 GENERAL PLANT INFORMATION .

8. INCLUDE A CHECK FOR THE AMOUNT IN SECTION 7, PAYABLE TO THE MISSOURI AIR POLLUTION CONTROL PROGRAM.

Mail the check for the emissions fee to the State Air Agency listed on Form 1.0.

7. ANNUAL EMISSIONS FEE REMITTED TO THE STATE (SECTION 5 MINUS SECTION 6)

CHECK DATE

Facilities within local air program jurisdiction only need to include copies of Form 1.0 General Plant Information , Form 3.0 Emissions

Fee Calculation and Form 4.0 Financial Cost Estimate with the emissions fee check.

CHECK NUMBER CHECK DATE CHECK AMOUNT

YEAR OF DATA

$

FACILITY NAME FIPS COUNTY NO. PLANT NO.
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 3.0 PART 70 OPERATING PERMIT EMISSIONS FEE CALCULATION

PM10 FIL SOX NOX VOC CO LEAD HAPs PM2.5 FIL NH3 PM CON

PM10 TOTAL SOX NOX VOC CO LEAD HAPs PM2.5 TOTAL NH3 PM CON

Included in Total

PM10 and PM2.5

NO FEES

FOR CO

NO FEES

FOR

PM2.5

NO FEES

FOR

NH3

PM CON is

included in PM10

and PM2.5

$

MO 780-2089 (04-10)

Facilities within local air program jurisdiction only need to include copies of Form 1.0 General Plant Information , Form 3.0 Emissions Fee

Calculation and Form 4.0 Financial Cost Estimate with the emissions fee check.

9. SEND THE COMPLETED QUESTIONNAIRE AND ANY SUPPORTING DOCUMENTATION TO THE AGENCY LISTED AT THE BOTTOM OF

FORM 1.0 GENERAL PLANT INFORMATION .

Mail the check for the emissions fee to the State Air Agency listed on Form 1.0 General Plant Information .

8. INCLUDE A CHECK FOR THE AMOUNT IN SECTION 7, PAYABLE TO THE MISSOURI AIR POLLUTION CONTROL PROGRAM.

6. ANNUAL EMISSIONS FEE REMITTED TO THE CITY OF KANSAS CITY OR ST. LOUIS COUNTY LOCAL AIR AGENCY

CHECK AMOUNT

AMOUNT REMITTED IN CALENDAR YEAR OF RECORD

CHECK NUMBER

FACILITY NAME FIPS COUNTY NO. PLANT NO.

1.

EMISSION UNIT

NO.

YEAR OF DATA

SCC

Use one row to list the emissions from one emission unit. Sum the emissions in the page total box at the bottom of the column. If

more than one page is needed, use the first row of the duplicated page to list the page totals from this page.

Express figures in tons per year and round to two decimal places.

CHECK NUMBER CHECK DATE

7. ANNUAL EMISSIONS FEE REMITTED TO THE STATE (SECTION 5 MINUS SECTION 6)

CHECK DATE

2. ACTUAL EMISSIONS (Use the sum of all page totals for each pollutant for actual emission figures below.)

Note: Fill out the lower portion of this form one time only.

AIR POLLUTANT

Total

3. CHARGEABLE EMISSIONS (Maximum 4,000 Tons/Yr. cap per pollutant.)

Copy the actual emissions from section 2 to the appropriate box(es) in the Total Plant Emissions Section of

Form 1.0 General Plant Information .

Total

PAGE TOTALS

4. SUM OF CHARGEABLE EMISSIONS SUBJECT TO FEES

Round chargeable emissions to the nearest whole ton. The minimum emission

tonnage is one ton, and the maximum is 12,000 tons per year.

Multiply the sum of chargeable emissions as calculated in section 4 by $40 and

enter this amount in section 5. The minimum fee is $40.

$

5. TOTAL ANNUAL EMISSIONS FEE
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 3.0 CK CHARCOAL KILN EMISSIONS FEE CALCULATION

PM10 SOX NOX VOC CO LEAD HAPs PM2.5 NH3

PM10 SOX NOX VOC CO LEAD HAPs PM2.5 NH3

NO FEES

FOR CO

NO FEES

FOR

PM2.5

NO FEES

FOR NH3

MO 780-1508 (12-09)

FACILITY NAME FIPS COUNTY NO. PLANT NO. YEAR OF DATA

Note: Fill out the lower portion of this form one time only.

6. INCLUDE A CHECK FOR THE AMOUNT IN BOX 5, PAYABLE TO THE MISSOURI AIR POLLUTION CONTROL PROGRAM.

PAGE TOTALS

Copy the actual emissions from section 2 to the appropriate box(s) in the Total Plant Emissions section of Form 1.0.

Tons/Yr.

3. CHARGEABLE EMISSIONS (Maximum 4,000 Tons/Yr. cap per pollutant)

2. ACTUAL EMISSIONS (Use the sum of all page totals for each pollutant for actual emission figures below.)

4. SUM OF EMISSIONS

Round figure to nearest ton per year

Use one row to list the emissions from one emission unit. Sum the emissions in the page total box at the

bottom of the column. If more than one page is needed, use the first row of the duplicated page to list the

EMISSION UNIT NO page totals from this page. Express figures in tons per year and round to two decimal places.

1.

SCC AIR POLLUTANT

5. TOTAL ANNUAL EMISSIONS FEE

Facilities within local air program jurisdiction only need to include copies for Form 1.0, 3.0 and 4.0 with the emissions fee check.

Mail the check for the emissions fee to the State Air Agency listed on Form 1.0.

Facilities that produce charcoal from wood are exempt from fees.

7. SEND THE COMPLETED QUESTIONNAIRE AND ANY SUPPORTING DOCUMENTATION TO THE AGENCY LISTED AT THE

BOTTOM OF FORM 1.0.
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

FORM 4.0 FINANCIAL COST ESTIMATE

FIPS COUNTY NO. PLANT NO. YEAR OF DATA

CODE FOR

PERSONNEL OR

EQUIPMENT

NUMBER OF

EMPLOYEES

TOTAL NUMBER

OF HOURS

REQUIRED

COST PER HOUR TOTAL COST

1.

2.

3.

4.

5.

MO 780-1622 (12-09)

FACILITY NAME

Calculate the cost and expenses incurred to complete the Emission Inventory Questionnaire, including the calculation of

emission fees. If you hired an outside consultant, include the time and money charged to your company. Also include any

cost incurred if you installed air pollution control equipment, any additional monitoring or testing expense or any additional

personnel costs incurred to comply with the Missouri Air Conservation Law and the Federal Clean Air Act, as amended.

Personnel and other costs

associated with complying with

the Clean Air Act, as amended,

not included above.

Estimate of the number of jobs

added to implement the Federal

Clean Air Act, as amended.

REMARKS

Total

The Missouri Air Conservation Law, Chapter 643, requires a financial cost estimate. The cost estimate is an evaluation of

any additional costs of doing business attributable to the Federal Clean Air Act, as amended.

Pollution control equipment,

monitoring, or testing

(List items separately).

EIQ completed by outside

engineering consultants.

EIQ reviewed and completed by

company personnel (engineers,

technical specialists, others).

Be sure to use the codes found in the instructions: www.dnr.mo.gov/env/apcp/eiq/eiqinformation.htm .

CATEGORY REPORTING
MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

EMISSIONS INVENTORY QUESTIONNAIRE, OR EIQ

DRY CLEANER - NON-CHLORINATED AND PETROLEUM BASED SOLVENTS

SEG. NO.

STATE

STATE

Lbs.

CHECK INFORMATION

MO 780-1954 (12-09)

SOLVENT TYPE (CHECK ONE)

Non-Chlorinated (Non-perc)

(b)

Gallons of

Sludge

×

Number of

Filters

= 0.1

4. SOLVENT DETAIL

3. MACHINE INFORMATION

NUMBER OF DRY TO DRY MACHINES NUMBER OF TRANSFER MACHINES TOTAL COMBINED DRYER CAPACITY

CITY STATE ZIP CODE +4

PARENT COMPANY NAME

STREET ADDRESS, P.O. BOX OR ROUTE NUMBER FAX NUMBER WITH AREA CODE

OWNER'S PHONE NUMBER WITH AREA CODE

2. PARENT COMPANY INFORMATION

MAILING ADDRESS (IF DIFFERENT FROM ABOVE) CITY ZIP CODE +4

STREET ADDRESS CITY ZIP CODE +4

FACILITY NAME PHONE NUMBER WITH AREA CODE FAX NUMBER WITH AREA CODE

1. DRY CLEANER INFORMATION

FIPS COUNTY NO. SCC YEAR OF DATA

PRINTED NAME AND TITLE OF PERSON COMPLETING FORM SIGNATURE OF PERSON COMPLETING FORM

PLANT NO. COUNTY EMISSION UNIT NO.

CHECK AMOUNT

(See instructions for current fee schedule).

CHECK DATE CHECK NO.

OFFICE USE ONLY

PRINTED NAME AND TITLE OF AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE OF AUTHORIZED COMPANY REPRESENTATIVE

EMISSION FEE LOGGED IN BY DATE RECEIVED

DATE

7. CERTIFICATION

Tons/Yr. (rounded to the nearest whole number)

Solvent Density lbs./gal.

=

DATE

2.

1.

$

5. CALCULATE GALLONS SOLVENT SHIPPED AS WASTE

(c)

Gallons on hand at end of calendar year (-)

Gallons on hand from previous year

Gallons brought on-site during calendar year (+)

Unused gallons transferred off-site (-)

×

Conversion Factor

(Default = 0.1)

× Emission Fee

Stoddard: 6.316 Other:

(a) Total gallons used during calendar year (=)

One ton minimum used to calculate fees

2,000 pounds per ton

[a-b-c] × Solvent Density

CONTACT PERSON NAME/TITLE

Calculate Solvent Use

The undersigned certifies that they have personally examined and are familiar with the information and statements contained herin

and further certifies they believe this information is true, accurate and complete. The undersigned certifies that knowingly making a

false statement or misrepresenting the facts presented in this document is a violation of state law.

6. CALCULATE AIR EMISSIONS FEE

Tons/Yr.



 *+,-./