1
ConstructionPermitApplication
PolkCountyPublicWorks‐AirQualityDivision
Instructionsthatwillassistinthecompletionofthepermitapplicationstartonpage7.
(1) CompanyName
LegalName:
(2) ResponsibleOfficial(RO)Certification(RO‐AsdefinedinBoardofHealthRules‐ChapterV)
Icertifythatbasedoninformationandbeliefformedafterreasonableinquiry,the
encloseddocumentsincludingtheattachmentsaretrue,accurate,andcomplete.
ResponsibleOfficial(RO)
Signature
(required):________________________________________Date:_________________
PrintName:_____________________________________________________________
Title:__________________________________________________________________
For O
f
f
ice UseOnly:
DateReceived_______________________
ConstructionPermit#____________________
Energov#_____________________________

Facility(AIRS#)_________________________

PermitFee$__________________________
Check#______________________________
IssueDate___________________________
(3) ResponsibleOfficial(RO)InvoicingandMailingInformation(required)
ROName: ROTitle:
ROTelephone#: ROEmail:
MailingAddress(Street): City: State: Zip:
(4) EquipmentLocationandFacilityContact(Thephysicallocationoftheemissionunit(EU)includedinthisapplication.)
FacilityContactName: FacilityContactTitle: Telephone#: Email:
StreetAddress: City: State:IA
County:Polk
Zip
IstheEquipmentPortable?
Yes,otherLocation(s):
No
(5) PermitPreparerorConsultantInformation
Name: Title: IowaP.E.Registration#(notrequired):
CompanyName: Telephone#: Email:
StreetAddress: City: State: Zip:
(6) PermitApplicationType‐
IdentificationofNewSourcePerformanceStandards(NSPS)orNationalEmissionStandardsforHazardousAirPollutants(NESHAP)
Newconstruction
Modificationofanexistingpermittedsource,providepreviousconstructionpermit#(s):_________________________________
Other,provideandexplanation:
NSPS&NESHAPApplicability
NSPS‐Isanyemissionunitinthisapplicationsubjecttoa40CFRPart60NSPS?
Yes,Listallapplicable(NSPS)foreachemissionunitincludedinthisapplication:____________________________________
No
NESHAP‐Isanyemissionunitinthisapplicationsubjecttoa40CFRPart61orPart63NESHAP?
Yes,Listallapplicable(NESHAP)foreachemissionunitincludedinthisapplication:__________________________________
No
2
(7) PrincipalActivityorProduct
Brieflydescribetheactivityofyourbusinessanditsprincipalproduct(s):
(8) NorthAmericanIndustryClassificationSystem(NAICS)andStandardIndustrialClassification(SIC)Information
PrimaryNAICS:__________________
_______________________________________________http://www.census.gov/eos/www/naics/
PrimarySIC:_______________________________________________________________https://www.osha.gov/pls/imis/sicsearch.html
(9) PermitApplicationFeesandSourceType
Major(FilingandReviewFee=$1650)
Minor(FilingandReviewFee=$358)
Government/Tax Exempt (FilingandReviewFee=$100)
$Amountenclosed: _____________
ConstructionPermitChecklist‐Beforesubmittingoftheconstructionpermitapplicationmakesuretoincludethefollowingitems:
Acompletedapplicationpacket.Allapplicablesectionshavebeencompleted.
SignatureoftheRO.
Applicablepermitfees.
3
EmissionUni
t(EU)Information
(OnepageperEU)
(1)CompanyName
LegalName:
EmissionUnitDescriptionandSpecifications
(1)EmissionUnit(EU)Name:
(2)EUIdentificationNumber:
(3)DateofConstruction:
(4)Manufacturer: (5)Model: (6)DateofModification(ifapplicable):
(7)MaximumCapacity: (8)StandardClassificationCode(if
known):
IsControlEquipmentAssociatedwithEU?
Yes
No
(9) ControlEquipment(CE)Name(ifany):
(10) ControlEquipmentIdentification#(ifany):
(11) PermitLimits
Areyourequestinganypermitlimits?
No
Yes
Ifyes,writedownallthatapply:
a. Hourlylimits:
b. Productionlimits:
c. Materialusagelimits:
d. Other:
*AnestimateofactualisrequiredonPage5,section6.
Rationaleforrequestingthelimit(s):
(12) ProductorMaterialFlowChart
Provideadescriptionand
adrawingtoshowquantitativelyhowproductormaterialflowsthroughthisemissionunit.Includeproductinputand
output,fuelthroughput,andanyparameterswhichimpactairemissions.Ifspacebelowisinsufficient,attachaseparatesheet.
4
ControlEquipment(CE)andStack/VentInformation
(1) CompanyName
LegalName:
ControlEquipment(CE)DescriptionandSpecifications
(1) ControlEquipment(CE)
NameandDescription:____________________________________________________________
NotApplicable
Ifapplicablecheckone.
Condensers
Adsorbers DryFilters CatalyticorThermal
Oxidation
Cyclones/SettlingChambers

ElectrostaticPrecipitators WetCollectionSystems Baghouses/FabricFilters
OtherMiscellaneous,provideadescription:______________________________________________________________
(2)ControlEquipment(CE)Identification#: (3)DateofInstallation: (4)Manufacturer:
(5)Model: (6)DateofModification(ifany):
(7)Isoperatingscheduledifferentthanemissionunit(s)controlled? No YesIfyes,specifytheschedule:
8) CaptureHoodInvolved? No Yes (9)CaptureEfficiency (10)EmissionUnits(EU(s))Controlled:
ControlEquipment(CE)andStackTestSupportingDocumentation
(1) Controlefficiencysupportingdocumentattached:
Manufacturer'sdesignspecificationsandperformancedata/guarantee
Stacktestreport
Pollutant(s)Controlled:
ControlEfficiency%:____
_
ProvideManufacturersperformancedataorcertification.
12) Ifmanufacturer'sdataisnotavailable,usespacebelow orattachaseparatesheettoprovidethecontrolequipment
designspecificationsandperformancedatatosupporttheabovementionedcontrolefficiency.
EmissionPoint(EP)StackorVentSpecifications
(13)EmissionPoint(EP)(Stack/Vent)Identification#: (14)Heightabove
ground:( )feet
(15) circularstack,diameteris( )inches
other,sizeis( )inchesxinches
(16)Dischargestyle: Vertical,withobstructingraincap
Vertical,withunobstructingraincaporwithoutraincap
Downwarddischarge
Horizontaldischarge
Other,pleasespecify
ExhaustInformation
17) RatedFlowRate:___________
_
acfm
scfm
(18)MoistureContent
%(ifknown):
(19)ExitTemperature(degreesF):
5
AQD‐ConstructionPermitApplication
SummaryofEmissionsbyEmissionPoint(EP)
(1)CompanyName
LegalName:
(2)EmissionPoint(EP)(Stack/Vent)Number(s):
(3)ProcessFlowDiagram
SummaryofemissionsfromtheEmissionPoint(EP)includedinthisapplication
(4)EmissionCalculation.Thesecalculationarebasedon(checkallthatapply): EmissionFactors RequestedLimits MassBalance TestingData Other,describe:
(5)EmissionPoint(EP):
PM
PM
10
PM
2.5
SO
2
NOx
VOC
CO
Lead
CARBONDIOXIDE
(tpy)
METHANE(tpy)
NITROUSOXIDE(tpy)
SULFUR
HEXAFLUORIDE
(lbs/yr)
HYDROFLUORO
CARBONS(lbs/yr)
PERFLUORO
CARBONS(lbs/yr)
Concentration

Emissions(Aftercontrolifapplicable) lbs/hr

tons/yearorlbs/yr

(6)EstimateofActualEmissions‐Actualemissionsaretheactualrateofairpollutionfromanemissionunit calculatedusingtheemissionunit’sactualoperatinghours,productionrates,andtypesof materials
processed,storedorcombustedforthecalendaryear.Generalequationforcalculatingactualemissionswithcontrolequipment:(ActualThroughput)x(EmissionFactor)x(ControlEfficiency)x(conversionfactortotons)=
tonsperyear.
EmissionPoint(EP):
PM
PM
10
PM
2.5
SO
2
NOx
VOC
CO
Lead
CARBONDIOXIDE
(tpy)
METHANE(tpy)
NITROUSOXIDE(tpy)
SULFUR
HEXAFLUORIDE
(lbs/yr)
HYDROFLUORO
CARBONS(lbs/yr)
PERFLUORO
CARBONS(lbs/yr)
Concentration

Emissions(Aftercontrolifapplicable) lbs/hr

tons/yearorlbs/yr

6
AQD‐ConstructionPermitApplication
SummaryofFacilityEmissions/Inventory(FACIILTYWIDE)
(1) CompanyName
LegalName:
EU/EPEmissionsSummaries
(1)
(2)
(3)
(4)
(5)PotentialorPermittedEmissionRates(tons/yrorlbs/yr)
EPID
EUID
SourceDescription
PermitNumber
PM
PM
10
PM
2.5
SO
2
NOx
VOC
CO
Lead
CARBONDIOXIDE(tpy)
METHANE(tpy)
NITROUSOXIDE(tpy)
SULFURHEXAFLUORIDE(lbs/yr)
HYDROFLUOROCARBONS(lbs/yr)
PERFLUOROCARBONS(LBS/YR)







(6)TotalStackEmission

(7)FugitiveSourceEmissionsSummary
FugitiveSourceID FugitiveSourceDescription PermitNumber,ifapplicable



(8)TotalFugitiveEmissions

(9)TotalFacilityEmissions

7
AQD‐ConstructionPermitApplication
ProvideaFacilityPlotPlan(MIPP)
(1) CompanyName
LegalName:
Istheplotplanincluded?
Yes
No,provideanexplanationwhytheplotplanwasnotincluded.
Instructionsforincludingtheplotplanisnecessaryforconstructionpermitprocessingandair
dispersionmodeling.
Ascaledplotplanoftheentireplantisrequired.Attachtheplotplan,labeledas"MIPP"withyourpermitapplication.Theplot
planmust:
1. Showascalebar andanortharrow.Thescalemustbeofsufficientsi
zetoallowdrawingstobeconvertedtoelectronic
format.
Simply stating that “1 inch = 80 feet” is not acceptable because the scale changes when the document’s size
changes.
2. Showpropertylines.
3. Showfencelinesorphysicalbarriers,ifany,precludingth
epublicaccess.
4. Showlocationsofallbuildingswithinpropertylines;allbuil
dingswithin200feetoutsidepropertylinesiftheirestimated
heightorwidthisatleast40feet;locationsoftiersonmultilevelbuildings.
5. Indicatethepeakheightofallbuildings,tiers,andstructures.Adescriptionofthebuildingsorstr
ucturesisoptional.
6. Showlocationsofall
emissionpoints.Emissionpointsymbolsneednotbetoscale.Allemissionpointsmustbemarked
withidentificationnumbers.ThenumbersMUST
beconsistentwithallformsintheapplication.Theidentification
numbersandassociatedemissionpointsmustbelegible(photocopiedplotplansmayblursmallprint).
7. Showlocationsofallstructuresabovegroundlevelandwithinpropertylines.Structuresabovegroundlevelsuchasa
gasolinestoragetank,grainstoragesilos,etc.,mustbeshown.Stru
cturesatgroundlevel,such
asconcretepads,paved
parkinglots,etc.,shouldnotbeontheplotplan.Openstructuresabovegroundlevel,suchaspowersubstations,neednot
beincluded.
8. Highlightormarktheemissionpointsthatarethesubjectofthispermitapplicationsotheyareclearlydistinguishedon
theplotpla
n.*
9. ForPSDprojects,showlocations
offugitivesourcessuchashaulroadsandstoragepiles.Drawtoscaleorindicatetheir
dimensions.
Note:
1. AutoCADorequivalentcomputeraiddrawingsondiskoronpaperarepreferred.
2. Sketchesarea
cceptableiftheyareclearlydrawn.Ifsketchescannotbemadetoscal
e,providelengthsofallsides
ofstructuresandtheirrespectivedistancestoallpropertylines.
3. Aerialphotographsarenotacceptable.
ExamplePlotPlan:

13
TABLEA:COMMONGREENHOUSEGASES
GAS CHEMICALFORMULA
Carbondioxide
CO
2
Methane
CH
4
NitrousOxide
N
2
O
Sulfurhexafluoride
SF
6
Hydrofluorocarbons:
HFC23
CHF
3
HFC32
HFC41
CH
2
F
2
CH
3
F
HFC125
HFC134
CHF
2
CF
3
CHF
2
CHF
2
HFC134a
HFC143
CH
2
FCF
3
CHF
2
CH
2
F
HFC143a
HFC152
CH
3
CF
3
CH
2
FCH
2
F
HFC152a
HFC161
CH
3
CHF
2
CH
3
CH
2
F
HFC227ea
HFC236cb
HFC236ea
CF
3
CHFCF
3
CH
2
FCF
2
CF
3
CHF
2
CHFCF
3
HFC236fa
HFC245ca
CF
3
CH
2
CF
3
CH
2
FCF
2
CHF
2
HFC245fa
HFC265mfc
CHF
2
CH
2
CF
3
CF
3
CH
2
CF
2
CH
3
HFC365mfc
CH
3
CF
2
CH
2
CF
3
HFC4310mee
CF
3
CHFCHFCF
2
CF
3
Perfluorocarbons:
Perfluoromethane(PFC14)
CF
4
Perfluoroethane(PFC116)
C
2
F
6
Perfluoropropane(PFC218)
C
3
F
8
Perfluorobutane(PFC3110)
C
4
F
10
Perfluorocyclobutane(PFC318)
cC
4
F
8
Perfluoropentane(PFC4112)
Nitro
g
enTrifluoride
C
5
F
12
NF
3
Perfluorohexane(PFC5114)
(PFC9118)
Trifluorometh
y
lSul
p
hurPentafluoride
C
6
F
14
C
10
F
18
SF
5
CF
3
* SenateFile485definesagreenhousegasasbeingcarbondioxide,methane,nitrousoxide,hydrofluorocarbons,
perfluorocarbons,andsulfurhexafluoride.
* Thisisnotanallinclusivelistandwillbeupdatedperiodically.
* ThechemicalformulaswereobtainedfromtheIntergovernmentalPanelonClimateChange(IPCC)WorkingGroup1:ThePhysical
BasisofClimateChange,Section2:ChangesinAtmosphericConstituentsandRadiactiveForcing
Thelinkisasfollows:http://ipccwg1.ucar.edu/wg1/wg
1report.html(page84of106).
14
Supplementalformsinsupportofaconstructionpermitapplication:
BoilerForm(FormB)
EngineForm(FormE)
ModelingDetermination(FormM)
Instructions: Supplemental forms B & E are used by the reviewer to become familiar with the
emission unit. Completion of Form M is intended to assist applicants in determining whether or not
point source emissions associated with non-PSD construction permit projects will require an air
dispersion modeling analysis. Modeling requirements for non-point source emissions will be
determined on a case-by-case basis. This procedure is used for both new construction permit projects
and for modifications to previous projects.
16
SupplementalInformationinsupportof aConstructionPermit
Application
BoilerForm(FormB)
BoilerDescription
EmissionPoint(EP)#
EmissionUnit(EU)#
EngineManufacturer
Model#
ModelYear
FuelType
RatedCapacity(MMBtu/hr)
BoilerSubcategory
(1)
CommenceConstructionDate
ReconstructionDate
(2)
ControlEquipmentDescription

(1)
Thesubcategoriesofboilersandprocessheaters,asdefinedin§ 63.7575are:
(a)
Pulverizedcoal/solidfossilfuelunits.
(b)
Stokersdesignedtoburncoal/solidfossilfuel.
(c)
Fluidizedbedunitsdesignedtoburncoal/solidfossilfuel.
(d)
Stokersdesignedtoburnbiomass/biobasedsolid.
(e)
Fluidizedbedunitsdesignedtoburnbiomass/biobasedsolid.
(f)
Suspensionburners/DutchOvensdesignedtoburnbiomass/biobasedsolid.
(g)
FuelCellsdesignedtoburnbiomass/biobasedsolid.
(h)
Hybridsuspension/grateburnersdesignedtoburnbiomass/biobasedsolid.
(i)
Unitsdesignedtoburnsolidfuel.
(j)
Unitsdesignedtoburnliquidfuel.
(k)
Unitsdesignedtoburnliquidfuelinnoncontinental Statesorterritories.
(l)
Unitsdesignedtoburnnaturalgas,refinerygasorothergas1fuels.
(m)
Unitsdesignedtoburngas2(other)gases.
(n)
Metalprocessfurnaces.
(o)
Limiteduseboilersandprocessheaters.
(2)
Amodificationisaphysicaloroperationalchangethatcanincreasetheemissionsofaregulatedair
pollutant.
Reconstructionisreplacingthecomponentsofanexistingengineandthecostofthereplacement
components
exceeds50%ofthecostofanewengine.See40CFR60.14and60.15forcompletedefinitions.
18
SupplementalInformationinsupportof aConstructionPermitApplication
EngineForm(FormE)
(
1)
Datetheenginewasordered.
(2)
EmergencystationaryinternalcombustionengineisastationaryICEwhoseoperationislimitedto
emergency
situationsandrequiredtestingandmaintenance.ExamplesincludestationaryICEusedtoproduce
poserfor
criticalnetworksorequipment(includingpowersuppliedtoportionsofafacility)whenelectric
powerfromthe
localutility(orthenormalpowersource,ifthefacilityrunsonitsownpowerproduction)is
interrupted,or
stationaryIceusedtopumpwaterinthecaseoffireorflood,etc.StationarySIICEusedto
supplypowertoan
electricgridorthatsupplypoweraspartofafinancialarrangementwithanotherentity
arenotconsideredtobe
emergencyengines.
(3)
Aportableenginethatwillremainatallocationmorethan12monthsoraportableenginethatoperates
more
than3monthsperyearaspartofaseasonalsourcethatreturnstothesamelocationisconsidereda
stationary
engine.
(4)
Amodificationisaphysicaloroperationalchangethatcanincreasetheemissionsofaregulatedair
pollutant.
Reconstructionisreplacingthecomponentsofanexistingengineandthecostofthereplacement
components
exceeds50%ofthecostofthenewengine.See40CFR60.14and60.15foracomplete
definition.
Emission Point (EP) #
Ignition Type
Emission Unit (EU) #
Black Start?
Engine Manufacturer
Emergency Engine?
(2)
Model #
2 or 4 Stroke? (SI Engine Only)
Model Year
Rich or Lean Burn? (SI Engine Only)
Fuel Type
Portable?
(3)
Rated Capacity (bhp)
Manufacturer Certified?
Displacement CI Only
(liters/cylinder)
Modification/Reconstruction Date
(4)
Date of Construction
(1)
Spark
Compression
Yes
No
Yes
No
2-Stroke
4-Stroke
Rich Burn
Lean Burn
Yes
No
Yes
No
20
SupplementalInformationinsupportof aConstructionPermit
Application
NONPSDMODELINGDETERMINATION(FORM–M)
CompanyName:
OfficeUse:
AIRS#:
Permit#:
Energov#
DISPERSIONMODELINGDETERMINATION
Completion of Form M is intended to assist applicants in determining whether or not point source emissions associated with nonPSD
constructionpermitprojects willrequireanair dispersionmodelinganalysis.Modelingrequirementsfornonpointsourceemissionswillbe
determined on a casebycase basis. This procedure is used for both new construction permit projects and for modifications to previous
projects.
This form reflects the Polk County Air Quality Division’s (AQD) Air Dispersion Modeling Applicability Procedure for NonPSD construction
permit applications. Please check the appropriate box below depending on whether the flow chart indicates that dispersion modeling is
requiredornot.
Note:ALLprojectsmustincludeasiteplan;seesectionPLOTPLANREQUIREMENTSforinstructions. Ascaledplotplanoftheentireplantis
required.Attachtheplotplan,labeledas"MIPP",withyourpermitapplication.
Note: Form Monly applies to point source emissions and should not be applied to internally venting vo
lume sources. Internally vented
sourceswillbeaddressedonacasebycasebasis.
DISPERSIONMODELINGANALYSISISNOTREQUIRED
Since the point source emissions in this application meet the criteria currently listed in the Air Dispersion Modeling Applicability
Procedure,itislikelythatmodeling isnotrequired.
ThereareuniquecircumstancesthattheAirDispersionModelingApplicabilityProceduredoesnotaddressthatmaytriggeramodeling
review.RecommendationsformodelingreviewsthatfalloutsideoftheAirDispersionModelingApplicabili
tyProcedurewillbereviewed
byPolkCountyAQDmanagement.
DISPERSIONMODELINGANALYSISISREQUIRED
When dispersion modeling is required, the modeling analysis is either conducted by the Polk County AQD or is submitted by the
applicantforPolkCountyAQDreviewasnotedbelow:
All applicants have the option to prepare and submit a complete dispersion modeling analysis, subject to review by the Polk
CountyAQD.
Formajorsourcesthathavepreviouslybeenmodeled,thePolkCountyAQDwillconductthemodeling analysisifresourcesallow.
Applicantswithextensivechangestotheirfacilitymayexpeditethemodelingreviewbysubmittingtheirownmodelinganalysis.
For major sources that have not previously been modeled, the applicant must prepare and submit the dispersion modeling
analysis.
Fornonmajorsources(minor),thePolkCountyAQDwillconducttheinitialdispersionmodelingasaservicetominorsourceswhena
modelinganalysishasnotbeensubmittedbytheapplicant.
21
Do the modeled impacts from this
project exceed any Significant
Impact Level?
Conduct facility-wide modeling of
the affected pollutants.
EVALUATION COMPLETE
No further modeling is required.
No
No
Yes
NONPSDMODELINGDETERMINATION(FORM–M)Continued:
 Pass
Pollutant Significant
Emission
Rate
NationalAmb
ientAirQualityStandard
(µg/m
3
)
SignificantImpac
tLevel(SIL)
(µg/m
3
)
1hour 3hour 8hour 24hour Annual 1hour 3hour 8hour 24hour Annual
PM10 3.42lb/hr 150 5
PM
2.5
2.28lb/hr 35 15 1.2 0.3
NO
2
9.13lb/hr 188 100 7.5 1
SO
2
*
9.13lb/hr 196 1,300 365 80 7.9 25 5 1
CO 22.8lb/hr 40,000 10,000 2,000 500
*
For1hourSO
2
:nodispersionmodelingiscurrentlyrequiredforminorprojects.Ambientairimpactevaluationwillberequiredinthefuture
State
ImplementationPlanrevision.
Were the most recently modeled
facility-wide impacts within one
significant impact level (SIL) of the
NAAQS for the pollutants be
evaluated in this project?
Conduct significant impact
modeling of the new project for the
affected pollutants only
Will the project result in a net
increase in potential emissions
equal to or greater that any of the
Significant Emission Rates?
(Refer to the table below.)
BEGIN HERE
Has facility-wide modeling been
conducted for this facility
previously?
No
Yes
No
Yes
Yes