### EPA Form 5900 - 04 OMB No. 2060 - 0336, Approval Expires 0 6 /30/201 5



### Federal Operating Permit Program (40 CFR Part 71) **AN NUA**  **L COMPLIA NCE CERT**  **IFICA TION (A**  **- COMP)**  **A. GENERA**  **L INFORMA TION**  Permit No. ____________________ Reporting Period: Beg.____/____/________ End.____/____/_______ Source / Company

Name ___________________________________________________________ Mailing Address: St reet or P.O. Box ________________________________________________ City ________________________________________ State______ ZIP__________ -

______ Contact person __________________________________ Title ___________________________ Tele phone (______) ______ - __________ Ext. ________ 

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EPA Form 5900 - 04 2 **B. COMPLIA**  **NCE STA TUS**  Describe the compliance status of each permit term for the reporting period. Copy this page as many times as necessary

to cover all permit terms and co nditions. Emission Unit ID(s): Permit Term (Describe requirements and cross - reference) Compliance Methods for the Above (Description and Citation): Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance Emission Unit ID(s) : Permit Term (Describe requirements and cross - reference) Compliance Methods for the Above (Description and Citation): Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance Emission Unit ID(s): Permit Term (Describe requi rements and cross - reference) Compliance Methods for the Above (Description and Citation): Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance Emission Unit ID(s): Permit Term (Describe requirements and cross - reference) Compliance Methods for the Above (Description and Citation): Status (Check one): ___ Intermittent Compliance ___ Continuous Compliance

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EPA Form 5900 - 04 3 **C. DEVIA** 

**TIONS FROM PERMIT TERMS A ND CONDITIONS**  Report all deviations from permit terms (whether reporte d previously or not) that occurred during the permit term. Cross - reference deviations already reported in the six - month report. Indicate whether each deviation is a A possible exception @ to compliance. @ Start and end period of each deviation should be in mo/day /y r, hr:min format (24 - hour clock). Also specify the date when the written deviation report was submitted (If written report required, but not submitted, leave the date field blank). Permit Term for W hich There was a Deviation: Emission Units (unit IDs): Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____ Date W ritten Report Submitted ____/____/________ Permit Term for W hich There was a Deviation: Emission Units (unit IDs): Deviation Start _____/

_____/_________ ____:____ End:_____/_____/_________ ____:____ Date W ritten Report Submitted ____/____/________ Permit Term for W hich There was a Deviation: Emission Units (unit IDs): Deviation Start _____/_____/_________ ____:____ End:__ ___/_____/_________ ____:____ Date W ritten Report Submitted ____/____/________ Permit Term for W hich There was a Deviation: Emission Units (unit IDs): Deviation Start _____/_____/_________ ____:____ End:_____/_____/_________ ____:____ Date Wr itten Report Submitted ____/____/________

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EPA Form 5900 - 04 4 **INSTRUCTIONS FOR A -**  **COMP AN**  **NUA L COMPLIA**  **NCE CERTIFICA TION**  **Information Collection Burden Estimates** The public reporting and recordkeeping burden for this collection of information is est imated to average 221 hours per respondent per y ear. 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 Pennsy lvania Ave., NW , W ashington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. **DETA ILED INSTRUCTIONS**  Submit this form along with a certification of truth, accuracy and completeness by

a responsible official on an annual basis. **Section A**

**(General Information)** Name and address should be consistent with information provided previously . The contact person should be a person familiar with the day - to - day operation of the facility , such as a plant site manager or other individual, who should be available to be contacted by the permitting authority . If there is more tha n one contact person, list the others on an attachment. The reporting period must be at least every 12 months, but y our permit may require this more frequently

. **Section B (Compliance Status**  **)** Description of Permit Term : Include each permit terms that im poses a requirement or action (emission limitations, standards, monitoring, recordkeeping, reporting, and other requirements on one or more emission units or on the facility

. Yo u will likely have to complete this section numerous times to include all requ irements in the permit. The emissions unit ID(s) should be those defined in the permit or in section I of form GIS . If the requirements, including compliance methods, apply in the same way

to multiple emission units, y ou may list multiple units for a p articular requirement. Emission units and requirements may be grouped if they apply the same way

at all units in the group, the same compliance methods apply to all, and all units have the same compliance status. Citations to the requirements should unam biguously identify the permit term to the lowest level. Compliance Methods : List all co mpliance methods (monitoring, recordkeeping and reporting) y ou used to determine compliance with the permit term described above. Also describe and cross reference t hese compliance methods. To describe monitoring, indicate the monitoring device, what is being monitored, averaging time, frequency , and cross - reference the permit term. To describe recordkeeping, describe the records kept, collection frequency , and cros s - reference the permit term. Please indicate whether monitoring data, results, or if compliance records are be kept on - site rather than reported. To describe reporting requirements, describe what is reported, when it is reported, and cross - reference the permit term. The citation or cross - reference here must unambiguously identify the requirement to the lowest level. Compliance Status : For each permit requirement and its associated compliance methods, indicate

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EPA Form 5900 - 04 5 whether there was intermittent or continuo us compliance (check one) during the reporting period. You should consider all available information or knowledge that y ou have when evaluating this, including compliance methods required by the permit and A credible evidence @ (e.g., non - reference test met hods and information A readily available @ to you). Yo u are always free to include written explanations and other information to clarify

y our conclusion regarding compliance status. Yo u must include permit terms that were not effective or not applicable (e.g., future - effective requirements, compliance options, and alternative scenarios). You may certify to continuous compliance for these if there is no evidence of noncompliance. Absent evidence to the contrary , you may certify continuous compliance bas ed on the data provided by the compliance methods, provided y ou did not fail to perform them and there were no unexcused deviations. Any failure to meet any

permit term for any

period of time indicates intermittent compliance. You may also indicate “unde termined compliance,” if y ou include the reason. **Section C (Deviations From Permit Terms an d**  **Conditions)** Summarize all deviations from permit terms that occurred since the last compliance certification. They may have been reported previously in - writing or they

may be reported concurrently with this certification. Also include any

deviations but have not y et been reported in writing. Copy this page as many

times as necessary

to include all deviations that occurred during the reporting period for this com pliance certification. Deviations occur when any permit term is not met, including emission limitations, standards, monitoring, recordkeeping, reporting and other requirements. For a more detailed explanation of the term A deviation, @ see the instructions for Form **SIXM ON**  . A deviation is not necessarily a violation. Violations are determined by

EPA (or its delegate Agency ). Yo u may cross - reference deviations previously reported (e.g., in 6 - month monitoring reports). Yo u must indicate whether each deviat ion is a A possible exception to compliance. @ This is a deviation that occurs when compliance is required. A deviation that is not a “possible exception to compliance” is one that occurs when compliance is not required or it is excused by another permit term. If you indicate that a deviation is not a possible exception to compliance, briefly explain and cross - reference the permit term that allows or excuses it. Also, deviations for which the permit provides an affirmative defense (e.g., emergencies) mus t be identified as “possible exception to compliance” because only the permitting authority may determine if the affirmative defense applies. If the cross - reference a deviation report that does not contain all the information requested here, y ou must supp lement it accordingly

. Yo u may list multiple emission units if they all had the same deviation during the same time periods. In addition, for deviations that impose requirements to the permitted facility as a whole or to all units at y our facility , yo u may

enter A facility - wide @ in the emissions unit column. Yo u may indicate continuous periods of deviation that span multiple day s 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 y ou did not submit a written deviation report during the reporting period c overed by the six - month monitoring report (whether required to do so or not). It is a deviation to fail to submit a required deviation report.

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EPA Form 5900 - 04 6 **Form CTAC**  **(Certification of Truth, Accuracy, and Completeness by Responsible Official)** Yo u must complete form **CTA C**  and attach it to this annual compliance certification.