DEPARTMENT OF ENVIRONMENTAL QUALITY AIR QUALITY DIVISION
PERMIT APPLICATION FORM
Date of Application:
1. Name of Firm or Institution
2. Mailing Address
Street City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin County Zip Telephone
3. Plant Location
4. Name of owner or company official to contact regarding air pollution matters
Name Title Street City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Zip Telephone
5. General nature of business
6. Permit application is made for: New Construction Modification Relocation Operation
7. Type of equipment to be constructed, modified, or relocated. (List each major piece of equipment separately.)
8. If application is being made for operation of an existing source in a new location, list previous location and new location:
Previous Location: Street City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin County Zip New Location: Street City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin County Zip
Previous Location: Street City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin County Zip
New Location: Street City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin County Zip
9. If application is being made for a crushing unit, is there: (mark all appropriate boxes)
10. Materials used in unit or process (include solid fuels):
11. Air contaminants emitted:
12. Air contaminant control equipment:
13. Type of combustion unit: (check if applicable):
A. Coal 1. Pulverized : General Dry Bottom Wet Bottom With Flyash Reinjection Without Flyash Reinjection Other Specify: 2. Spreader Stoker : With Flyash Reinjection Without Flyash Reinjection Cyclone Hand-Fired Other Specify: B. Fuel Oil Horizontally Fired Tangentially Fired C. Natural Gas D. If other, please specify Hourly fuel consumption (estimate for new equipment) /hr. Size of combustion unit BTU heat input/hour.
A. Coal
1. Pulverized : General Dry Bottom Wet Bottom With Flyash Reinjection Without Flyash Reinjection Other Specify:
2. Spreader Stoker : With Flyash Reinjection Without Flyash Reinjection Cyclone Hand-Fired Other Specify:
B. Fuel Oil Horizontally Fired Tangentially Fired
C. Natural Gas
D. If other, please specify
Hourly fuel consumption (estimate for new equipment) /hr.
Size of combustion unit BTU heat input/hour.
14. Operating Schedule:
hours/day hours/year days/week weeks/year Peak production season (if any):
hours/day hours/year days/week weeks/year
Peak production season (if any):
15. Fuel analysis:
16. Products of process or unit:
17. Emissions to the atmosphere (each point of emission should be listed separately and numbered so that it can be located on the flow sheet):
18. Does the input material or product from this process or unit contain finely divided materials which could become airborne?
Yes No Is this material stored in piles or in some other way as to make possible the creation of dust problems? Yes No List storage pile (if any):
Yes No
Is this material stored in piles or in some other way as to make possible the creation of dust problems?
List storage pile (if any):
19. Using a flow diagram:
(1) Illustrate input of raw materials. (2) Label production processes, process fuel combustion, process equipment, and air pollution control equipment. (3) Illustrate locations of air contaminant release so that emission points under items 11, 12 and 17 can be identified. For refineries show normal pressure relief and venting systems. Attach extra pages as needed.
20. A site map should be included indicating the layout of facility at the site. All buildings, pieces of equipment, roads, pits, rivers and other such items should be shown on the layout.
21. A location drawing should be included indicating location of the facility with respect to prominent highways, cities, towns, or other facilities (include UTM coordinates).
"I certify to the accuracy of the plans, specifications, and supplementary data submitted with this application. It is my Opinion that any new equipment installed in accordance with these submitted plans and operated in accordance with the manufacturer's recommendations will meet emission limitations specified in the Wyoming Air Quality Standards and Regulations."
Signature:_______________________________________
Typed Name Title Company Mailing Address Telephone No. City State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Zip P.E. Registration (if applicable) State where registered Wyoming None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin