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

1

ConstructionPermitApplication

PolkCountyPublicWorks‐AirQualityDivision

 Instructionsthatwillassistinthecompletionofthepermitapplicationstartonpage7.

(1) CompanyName

LegalName:

(2) ResponsibleOfficial(RO)Certification(RO‐AsdefinedinBoardofHealthRules‐ChapterV)

Icertifythatbasedoninformationandbeliefformedafterreasonableinquiry,the

encloseddocumentsincludingtheattachmentsaretrue,accurate,andcomplete.

ResponsibleOfficial(RO)

Signature

(required):________________________________________Date:_________________

PrintName:_____________________________________________________________

Title:__________________________________________________________________

For O

ice UseOnly:

DateReceived_______________________

ConstructionPermit#____________________



Energov#_____________________________



Facility(AIRS#)_________________________



PermitFee$__________________________



Check#______________________________



IssueDate___________________________



(3) ResponsibleOfficial(RO)–InvoicingandMailingInformation(required)

ROName: ROTitle:

ROTelephone#: ROEmail:

MailingAddress(Street): City: State: Zip:

(4) EquipmentLocationandFacilityContact(Thephysicallocationoftheemissionunit(EU)includedinthisapplication.)

FacilityContactName: FacilityContactTitle: Telephone#: Email:

StreetAddress: City: State:IA

County:Polk

Zip

IstheEquipmentPortable?

Yes,otherLocation(s):

No

(5) PermitPreparerorConsultantInformation

Name: Title: IowaP.E.Registration#(notrequired):

CompanyName: Telephone#: Email:

StreetAddress: City: State: Zip:

(6) PermitApplicationType‐

IdentificationofNewSourcePerformanceStandards(NSPS)orNationalEmissionStandardsforHazardousAirPollutants(NESHAP)

Newconstruction

Modificationofanexistingpermittedsource,providepreviousconstructionpermit#(s):_________________________________

Other,provideandexplanation:

NSPS&NESHAPApplicability

NSPS‐Isanyemissionunitinthisapplicationsubjecttoa40CFRPart60NSPS?

Yes,Listallapplicable(NSPS)foreachemissionunitincludedinthisapplication:____________________________________

No

NESHAP‐Isanyemissionunitinthisapplicationsubjecttoa40CFRPart61orPart63NESHAP?

Yes,Listallapplicable(NESHAP)foreachemissionunitincludedinthisapplication:__________________________________

No

Phone: (515)-286-3705

Fax: (515)-286-3437

Email: airquality@polkcountyiowa.gov

Operating Hours: 7am - 4:30pm / M-F

Mailing Address:

Polk County Public Works- Air Quality Division

5885 NE 14 Street

Des Moines, IA 50313

2

(7) PrincipalActivityorProduct

Brieflydescribetheactivityofyourbusinessanditsprincipalproduct(s):

(8) NorthAmericanIndustryClassificationSystem(NAICS)andStandardIndustrialClassification(SIC)Information

PrimaryNAICS:_________________________________________________________________http://www.census.gov/eos/www/naics/

PrimarySIC:_______________________________________________________________

https://www.osha.gov/pls/imis/sicsearch.html

(9) PermitApplicationFeesandSourceType



Major(FilingandReviewFee=$1900)

Minor(FilingandReviewFee=$565)

Government/TaxExempt(FilingandReviewFee=$155)

$Amountenclosed: _____________

ConstructionPermitChecklist‐Beforesubmittingoftheconstructionpermitapplicationmakesuretoincludethefollowingitems:

Acompletedapplicationpacket.Allapplicablesectionshavebeencompleted.

SignatureoftheRO.

Applicablepermitfees.

3

EmissionUnit(E

U)Information

(OnepageperEU)

(1) CompanyName

LegalName:

EmissionUnitDescriptionandSpecifications

(1) EmissionUnit(EU)Name:

(2) EUIdentificationNumber:

(3) DateofConstruction:

(4) Manufacturer: (5) Model: (6) DateofModification(ifapplicable):

(7) MaximumCapacity: (8) StandardClassificationCode(if

known):

IsControlEquipmentAssociatedwithEU?

Yes

No

(9) ControlEquipment(CE)Name(ifany):

(10) ControlEquipmentIdentification#(ifany):

(11) PermitLimits

Areyourequestinganypermitlimits?

No

Yes

Ifyes,writedownallthatapply:

a. Hourlylimits:

b. Productionlimits:

c. Materialusagelimits:

d. Other:

*AnestimateofactualisrequiredonPage5,section6.

Rationaleforrequestingthelimit(s):

(12) ProductorMaterialFlowChart

Provideadescriptionand

adrawingtoshowquantitativelyhowproductormaterialflowsthroughthisemissionunit.Includeproductinputand

output,fuelthroughput,andanyparameterswhichimpactairemissions.Ifspacebelowisinsufficient,attachaseparatesheet.

4

ControlEquipment(CE)andStack/VentInformation

(1) CompanyName

LegalName:

ControlEquipment(CE)DescriptionandSpecifications

(1) ControlEquipment(CE)

NameandDescription:____________________________________________________________

NotApplicable

Ifapplicablecheckone.

Condensers

Adsorbers DryFilters CatalyticorThermal

Oxidation

Cyclones/SettlingChambers



ElectrostaticPrecipitators WetCollectionSystems Baghouses/FabricFilters

Other–Miscellaneous,provideadescription:______________________________________________________________

(2) ControlEquipment(CE)Identification#: (3) DateofInstallation: (4) Manufacturer:

(5) Model: (6) DateofModification(ifany):

(7) Isoperatingscheduledifferentthanemissionunit(s)controlled? No YesIfyes,specifytheschedule:

8) CaptureHoodInvolved? No Yes (9) CaptureEfficiency (10) EmissionUnits(EU(s))Controlled:

ControlEquipment(CE)andStackTestSupportingDocumentation

(1) Controlefficiencysupportingdocumentattached:

Manufacturer'sdesignspecificationsandperformancedata/guarantee

Stacktestreport

Pollutant(s)Controlled:

ControlEfficiency%:____



ProvideManufacturersperformancedataorcertification.

12) Ifmanufacturer'sdataisnotavailable,usespacebelow orattachaseparatesheettoprovidethecontrolequipment

designspecificationsandperformancedatatosupporttheabove‐mentionedcontrolefficiency.

EmissionPoint(EP)StackorVentSpecifications

(13) EmissionPoint(EP)(Stack/Vent)Identification#: (14) Heightabove

ground:( )feet

(15) circularstack,diameteris( )inches

other,sizeis( )inchesxinches

(16) Dischargestyle: Vertical,withobstructingraincap

Vertical,withun‐obstructingraincaporwithoutraincap

Downwarddischarge

Horizontaldischarge

Other,pleasespecify

ExhaustInformation

17) RatedFlowRate:___________

acfm

scfm

(18) MoistureContent

%(ifknown):

(19) ExitTemperature(degreesF):

5

AQD‐ConstructionPermitAppli

cation

SummaryofEmissionsbyEmissionPoint(EP)

(1) CompanyName

LegalName:

(2) EmissionPoint(EP)(Stack/Vent)Number(s): (3) ProcessFlowDiagram

SummaryofemissionsfromtheEmissionPoint(EP)includedinthisapplication

(4) EmissionCalculation.Thesecalculationarebasedon(checkallthatapply): EmissionFactors RequestedLimits MassBalance TestingData Other,describe:

(5) EmissionPoint(EP):

PM



2.5



NOx

VOC

CO

Lead

CARBONDIOXIDE

(tpy)

METHANE(tpy)

NITROUSOXIDE(tpy)

SULFUR

HEXAFLUORIDE

(lbs/yr)

HYDROFLUORO

CARBONS(lbs/yr)

PERFLUORO

CARBONS(lbs/yr)

Concentration

Emissions(Aftercontrolifapplicable) lbs/hr

tons/yearorlbs/yr



(6) EstimateofActual Emissions‐Actual emissions are the actual rate of airpollution from an emission unit calculated using the emission unit’s actual operating hours, production rates, and types of materials

processed,storedorcombustedforthecalendaryear.Generalequationforcalculatingactualemissionswithcontrolequipment:(ActualThroughput)x(EmissionFactor)x(ControlEfficiency)x(conversionfactortotons)=

tonsperyear.

EmissionPoint(EP):

PM



2.5



NOx

VOC

CO

Lead

CARBONDIOXIDE

(tpy)

METHANE(tpy)

NITROUSOXIDE(tpy)

SULFUR

HEXAFLUORIDE

(lbs/yr)

HYDROFLUORO

CARBONS(lbs/yr)

PERFLUORO

CARBONS(lbs/yr)

Concentration

Emissions(Aftercontrolifapplicable) lbs/hr

tons/yearorlbs/yr



6

AQD‐ConstructionPermitAppli

cation

SummaryofFacilityEmissions/Inventory‐(FACIILTY‐WIDE)

(1) CompanyName

LegalName:

EU/EPEmissionsSummaries

(1) (2) (3) (4) (5) PotentialorPermittedEmissionRates(tons/yrorlbs/yr)

EPID EUID SourceDescription PermitNumber

PM



2.5



NOx

VOC

CO

Lead

CARBONDIO

XIDE(t

py)

METHANE(tpy

)

NITROUSOXID

E(tpy)

SULFURHEXA

FLUORIDE(lbs/yr)

HYDROFLUOROCARBONS(lbs/

yr)

PERFLUOROCARBONS(LB

S/YR)

(6) TotalStackEmission

(7) FugitiveSourceEmissionsSummary

FugitiveSourceID FugitiveSourceDescription PermitNumber,ifapplicable

(8) TotalFugitiveEmissions

(9) TotalFacilityEmissions

7

AQD‐ConstructionPermitApplication

ProvideaFacilityPlotPlan(MI‐PP)

(1) CompanyName

LegalName:

Istheplotplanincluded?

Yes

No,provideanexplanationwhytheplotplanwasnotincluded.

Instruc

tionsforincludingtheplotplanisnecessaryforconstructionpermitprocessingandair

dispersionmodeling.

Ascaledplotplanoftheentireplantisrequired.Attachtheplotplan,labeledas"MI‐PP"withyourpermitapplication.Theplot

planmust:

1. Show a scale bar and a north arrow. The scale must be of sufficient si

ze to allow drawings to beconverted to electronic

format. Simply stating tha

t “1 inch = 80 feet” is not acceptable because the scale changes when the document’s size

changes.

2. Showpropertylines.

3. Showfencelinesorphysicalbarriers,ifany,precludingth

epublicaccess.

4. Showlocationsofallbuildingswithinpropertylines;allbuildingswithin20

0feetoutsidepropertylinesiftheirestimated

heightorwidthisatleast40feet;locationsoftiersonmulti‐levelbuildings.

5. Indicatethepeakheightofallbuildings,tiers,andstructures.Adescriptionofthebuildingsorstr

ucturesisoptional.

6. Showlocationsofall

emissionpoints.Emissionpointsymbolsneednotbetoscale.Allemissionpointsmustbemarked

withidentificationnumbers.ThenumbersMUST

beconsistentwithallformsintheapplication.Theidentification

numbersandassociatedemissionpointsmustbelegible(photocopiedplotplansmayblursmallprint).

7. Showlocationsofallstructuresabovegroundlevelandwithinpropertylines.Structuresabovegroundlevelsuchasa

gasolinestoragetank,grainstoragesilos,etc.,mustbeshown.Stru

cturesatgroundlevel,suchasconcr

etepads,paved

parkinglots,etc.,shouldnotbeontheplotplan.Openstructuresabovegroundlevel,suchaspowersub‐stations,neednot

beincluded.

8. Highlightormarktheemissionpointsthatarethesubjectofthispermitapplicationsotheyareclearlydistinguishedon

theplotpla

n.*

9. ForPSDprojects,showlocationsoffug

itivesourcessuchashaulroadsandstoragepiles.Drawtoscaleorindicatetheir

dimensions.

Note:

1. AutoCADorequivalentcomputer‐aiddrawingsondiskoronpaperarepreferred.

2. Sketchesarea

cceptableiftheyareclearlydrawn.Ifsketchescannotbemadetoscale,provide

lengthsofallsides

ofstructuresandtheirrespectivedistancestoallpropertylines.

3. Aerialphotographsarenotacceptable.

ExamplePlotPlan:

7

Page1and2Instructions:

This construction permit application is used by Polk County to identify a company or facility, equipment locations, and

personnel involved in the permit application. Additional information may be requested.

1. Providethenameofthecompanyororganizationapplyingforthepermit.

2. Fillinthecertificationsectionwithasignature,name,titleanddate.Thecertificationmustbesignedbyaresponsible

official,asdefinedinBoardofHealth–ChapterV.

3. Providetheresponsibleofficial,name,title,address,emailandtelephone.numberofthepersonwho

canbereached

forquestionsaboutyourpermitapplicationduringthereview.

4. Providethefacilitycontact,name,title,address,emailandtelephonenumberofthepersonwhocanbereachedfor

questionsaboutyou

rpermitapplicationduringthereview.Iftheequipmenttobepermittedisatadifferentlocation

thantheplantpermitcontactperson'saddress,givethea

ddresshere.Iftheequipmentisatthesamelocation,mark

"same".Iftheequipmentisportable(suchasanasphaltplant),identifybymarking"yes"here.Also,ifthereareothe

knownlocationswhereportableequipmentwillbeused,writethelocation(s)beside"Oth

erlocation(s)".Attacha

separatesheet,ifneeded,tolistmultiplelocations.

5. Ifthepermitapplicationhasbeenpreparedbyaconsultant,providethename,address,etc.,oftheconsultant.An

IowaProfessionalEngineeringregistratio

nnumbershouldbeavailablefromtheconsultant.Ifthepermitapplication

wasprepare

dbyacompanyemployeewhoisnotaregisteredProfessionalEngineer,thenleavethisblank.

6. Markthetypeofpermityouareapplyingfor,suchasanewsourcewhichhasnotbeenconstr

ucted,anexisting

permittedsourcethatisbeingmodified,oranexistingsource(as‐built)thatisapplyingforapermitfo

rthefirsttime.

MarktheEmissionUnitsSubjecttoNSPS:ListallapplicableNewSourcePerformanceStandards(NSPS)foreach

emissionunitincludedinthisapplication.TolocatepossibleNSPSrulesanemissionun

itmaybesubjecttovisitEPA’s

websiteathttp://www.access.gpo.gov/

nara/cfr/waisidx_09/40cfr60_09.html

MarktheEmissionUnitsSubject

toNESHAP:ListallapplicableNationalEmissionStandardsforHazardousAir

Pollutants(NESHAP)foreachemissionunitincludedinthisapplication.Part63NESHAPregulationsapplytosources

ofhazardousairpollutants.AlistofhazardousairpollutantsmaybefoundonEPA’swebsiteat

http://www.epa.gov/ttn/

atw/orig189.html

Part61NESHAPregulationsapplytosourcesofthefollowingpollutants:

beryllium,mercury,vinylchloride,radionuclides,benzene,asbestosandarsenic.Therulegoverningthesepollutants

maybefoundathttp://www.access.gpo.gov/cgi‐bin/cfrassemble.cgi?title=200940

Tolocatespecif

icrulesforsourcecategoriesvisitEPA’swebsiteathttp://www.epa.gov/ttn/atw/mactfnlaph.html

7. Brieflydescribe

theprimaryactivityandprincipalproductofyourbusiness.

8. ProvidetheNAICScodeforyourbusiness.TheNorthAmericanIndustryClassificationSystem(NAICS)isthestandard

usedbyFederalstatisticalagenciesinclassifyingbusinessestablishmentsforthepurposeofcollecting,analyzing,and

publishingstatisticaldatarelatedtotheU.S.businessec

onomy.

ProvidetheSICcode(ifknow

n)foryourbusiness.TheStandardIndustrialClassificationcodesareacompilationby

thefederalgovernmentofbusinessesbytypeofactivityinwhichtheyareengaged.StandardIndustrialClassification

(SIC)codesareintendedtocovertheentirefieldofeconomicactivity.

NorthAmerica

nIndustryClassificationSystem(NAICS),http://www.census

.gov/eos/www/naics/

StandardIndust

rialClassification(SIC),https://osha.gov/pls/imis/sicsearch.html

9. Calculateyourpermitfee.Ifapplicable,pro

videdocumentationshowingthecostofthenewcontrol

equipment.Do

notincludethenewcontrol

equipmentinstallationcost.

See Fee Schedule

10

Page3In

structions:

This construction permit application is designed to provide Polk County about the emission unit (EU), including a

written description of how product and/or material flow through the emission unit. An emission unit is the equipment

or process which generates emissions of regulated air pollutants. This form is used by the reviewer to become familiar

with the emission unit.

Pleaseputyourcompanynameintheboxprovided.Thisisusefulincaseanypagesoftheapplicationgetseparated.

1. Providethenameoftheemissionunit,suchas"paintbooth","boiler",“generator”,etc.

2. Providetheidentificationnumberoftheemissionunit.Th

isnumberisusedforthispermitapplicationto

identifytheemissionunit.Itcanbeanynumber.However,ifyousubmit

tedaTitleVpermitapplication,the

numbersusedforidentificationpurposesinthisapplicationshouldbeconsistentwiththeIDnumbersusedin

yourTitleVapplication.Also,theIDnumbershouldmatchtheIDnu

mbersusedonotherconstructionpermit

applicationsandwithinthisapplication.

Eachemissionunitintheapplicationmusthaveitsownnumber.If

therearemultipleemissionunitswhichareinvolvedinthispermitapplicationandtheyarenotidentical,fillout

aseparateformforeachemissionunit.Ifyouhavetwoemissionunitsgoingtoonecontroldevicewithone

stack,filloutaformforbo

themissionunitsiftheyarenotidentical.Iftheemissionunitsareidentical,attacha

separatesheetlistingeachemissionunitbyname,number,dateofcons

truction,dateofmodification(if

applicable)andanyotherinformationwhichisdiffere

nt.

3. Thedateofconstructionoftheemissionunitisthedate,month,andyearinwhichconstructionormodification

beginsasdefinedinChapterVofthePolkCountyBoardofHealthRulesandRegulations.

4. Providethemanufactureroftheemissionunit'sname.Iftheunitiscustom‐designedorhomemade,indicate

thisontheapplication.

5. Providethemodelnumberoftheemissionunit.Iftheunitiscustom‐designe

dorhomemade,indicatethis.

6. Iftheemissionunithasbeenorwillbemodified,givethedate,monthandyearofthemostrecentorfuture

modification.

7. Providethemax

imumcapacityoftheemissionunitorprocesswhichisgeneratingemissionsofairpollutants.

Forexample,abakeovenwouldhaveacap

acityintermsofheatinputofnaturalgasitisfueledon(in

MMBtu

/hr);anassemblylinewouldhaveacapacityofpartsproducedperday.Thiscapacityshouldbebased

onaratednameplateormanufacturer'sliteraturecapacity.

8. TheSourceClassificationCode(SCC)re

presentsauniqueprocessorfunct

ionwithinasourcecategory

associatedwithapointofairpollutionemissions.SCC'sweredevelopedbytheEPAtoaidinclassifyingand

tabulatingairpollutionemissions.SCCstrytoestimatetheemissionsofthesixcriteriapollutantsbyproviding

emissionfactorsforvariousindustrialprocesses.Forexample,ifyouhav

eaprocessheaterfueledonnatural

gaswitharati

ngif50MMBtu/hr,thenyourSCCcodeis1‐02‐006‐02andthereareemissionfactorslistedto

estimatetheemissionsofthesixcriteriapollutantsfromyourprocessheater.Ifyoudonotknowtheemission

unit'sSCCcod

e,thenleavethisblank.

9. Providethecontroldevicename,ifth

ereisacontroldeviceattachedtothisemissionunit.Thenameand

numberofthecontroldeviceshouldbeconsistentthroughouttheapplication.

10. Providethecontrolequipmentnumber,ifthereisacontr

oldeviceattachedtothisemissionunit.Thenameand

numberofthecontroldeviceshouldbeconsistent

throughouttheapplication.

11. Ifyouwishtohavepermitlimitsplacedontheemissionunitmark"Yes".Then,writedowneachtypeoflimit

thatappliestoyourpermitapplicationandpu

ttherequestedlimit.Forexample,productionlimitsmaybein

termsofpartsprodu

cedperyear,materialusagelimitsmaybeingallonsperday.Ifrequestingapermit

limit(s),indicatethereasonfortherequestedlimit.ThisistohelpPolkCountyandtheapplicantdetermine

whethertheli

mitsarenecessary,andwhetherornottheywillaccomplishthedesiredpurpose.

12. The

processdescriptionshouldincludewhatrawmaterialsorproductsenterandexittheemissionunit,how

theyflowthroughtheemissionunit,anyfuelusagewhichoccursattheemissionunit,andanyothermaterial

orprod

uctwhichflowsintoandoutoftheemissionunit.

10

Page4Instr

uctions:

This construction permit application is used by Polk County to identify the control equipment and the emission

point (stack or vent) used for the emission unit(s) proposed in this permit application. This form also asks for

supporting documents to verify stated control efficiencies and details about the emission point. Additional

information may be requested.

Pleaseputyourcompanynameintheboxprovided.Thisisusefulincaseanypagesoftheapplicationgetseparated.

1. Providethenameofthetypeofcontroldeviceused.IFTHEREISNOCONTROLDEVICEATTACHEDTOTHE

EMISSIONUNITDESCRIBEDIN(1

)MARK“NotApplicable”ANDGOTOBOXES(13)THROUGH(19).

2. Identifythecon

troldevicebynumber.Thisnumbershouldmatchnumbersusedinotherpermitapplicationsand

beconsistentwithinthisapplication.

3. Providethedatethecontroldevicewasinstalledorwillbeinstalledattheemissionunit(

s).

4. Providethemanufacturer'snameforthecon

troldevice.Ifcustom‐designedorhomemade,indicatehere.

5. Providethemodelnumberforthecontroldevice.Ifcustom‐designedorhomemade,indicatehere.

6. Ifthecontroldevicehasbeenorwillbemodified,writethedate,monthandyearofthemodification.

7. Indica

tewhetherthecontroldeviceoperatesonthesamescheduleastheemissionunititcontrols.Ifitdoesnot,

write

downwhatthescheduleis.

8. Indicatewhetherthereisacapturehoodassociatedwiththeemissionunit.

9. Ifthereisacapturehood,writedownitsca

ptureefficiency,ifknown.

10. Writedowntheemissionunitnumber(s)thatarecontrolledbythisco

ntroldevice.

11. Ifyouhavesupportingdocumentationforthecontrolefficiency(s)ofthecontrolequipmentmarkthetypeof

documentationyouhave,eithermanufacturer'sdataorstacktestingreport.Manufacturer'sdatacanincludea

manufacturer'sguara

nteedemissionrateorguaranteedcontrolefficien

cy.Attachthesupportingdocumentation

andlabelthisattachment.Then,listthepollutantandprovidetheestimatedorprovencontrolefficiencyforthe

controldeviceonthisform.Ifthecontroldevicewillbecontrollingmorethanonepollutantatthisemissionunit,

listallpollutantsandthecorr

espondingefficiencies.

12. Ifyoudonothavethedocume

ntationrequestedinbox(11),provideotherdocumentationforthecontrol

efficiencysuchascalculationsordesigndataorotherreferencedocument.Youmayusethespaceinbox(12)or

attachaseparatesheet.

13. Providethenu

mber(s)oftheemissionpoint(s).Anemissionpointisthesameasa

stackorvent.

14. Providetheheightofthetopoftheemissionpoint(s)aboveground.Ifyouhavemultiplestacksfromoneemission

unitorcontroldevice,attachasheetthatgivestheinform

ationrequestedin(13)‐(16)foreachstack.

15. Indicatebych

eckingaboxwhetherthestackorventopeningiscircularorothershapeandwriteinthedimensions

oftheopening.

16. Indicatebycheckingaboxwhatthedischargestyleis.

17. Ifthereisafanwiththeemissionpoint

,givetheratedcapacityofthefanin

actualorstandardcubicfeet.18.Providethemoisture

content,inpercent,ofthe

exhaustgas,ifknown.Ifunknown,leaveblank.19.Providethetemperatureofthe

exhaustattheemissionpointindegreesFahrenheit.

20. CollectionofGreenhouseGas(GHG)EmissionsDat

a‐StartingonJuly2,2007,constructionpermitapplications

mustincl

udepotentialgreenhousegasemissionsfortheproject.Applicationsreceivedwithoutthisinformation

willbeconsideredincompleteandthepermit(s)cannotbeissueduntiltheinformationhasbeenreceived.The

followingaretheGHGemissionsthatmustbea

ccounted:

(a) CO

:Carbondioxide.

(b) CH

:Meth

ane.

O:Nitrousoxide.Alsoknownasdinitrogenoxideordinitrogenmonoxideorlaughinggas.

(d) SF

:Sulfurhexafluoride.

(e) HFC:Hydrofluorocarbons:SEETABLEA:COMMONGREENHOUSEGASES

(f) PFC:Perfluorocarbons: SEETABLEA:COMMONGREENHOUSEGASES

10

Page5Instructions:

This construction permit application is used by Polk County to better understand the process that is being permitted

and to verify the emissions calculations and how they are calculated.

1. Providecompanyname.

2. Providethenumberoftheemissionpoint(stack(s)orvent(s))throughwhichtheemissionunit(s)willexhaustintothe

atmosphere.Thisshouldbethesamenumberasonallotherformssubmitted.

3. ProcessFlowDiagram:

Identifyallemissionunits,showingth

epathwayofairemissionsfromeachemissionunitthrougheachcontroldevice

(if

any)tothestackofvent(seeexamplesbelow).Identificationnumbersusedintheflowdiagrammustbeconsistent

throughoutthisapplication.Youmayusethisformorattachanotherdiagramifitprovidesalltheinfor

mation

required.

4. EmissionCalculations:

Checktheappropriateboxtoindicatethebasisforemissioncalculations.Showemissionscalculationsindet

ailfor

actualandpotentialtoemitforeachairpollutantemittedfromthisemissionpoint.Includeadescriptionofany

assumptionsusedinmakingthecalculations.Ifmorespaceisneede

d,attachan8.5"x11"sheet(s)labeled

accor

dingly.

5. Summarizetheemissionscalculationsinthistableforeachairpollutantemittedfromthisemissionpoint(stackor

vent).Emissionsshouldbecalculatedaspotentialtoemit.Potentialtoemitistheuncontrolledemissionsat

maximumdesignorachievablecapa

city(whicheverishigher),andyear‐ro

undcontinuousoperation(8760hoursper

year).IFtherearenofederally‐enforceablepermitlimitsonthesource.Iftheemissionpointwillhaveacontrol

deviceorsomeotherproposedpermitlimitationsuchashoursofoperationormaterialusage,thiscanbeusedin

calculatingpotentialtoemit.Forpollutantdefinitions,refertoFormEIinstructionsnumber5.Indicatethe

concentrationunitforeachpollutant.Concentrationisusuallyexpressedingrainsperstandardcubicfeetfor

particulates,andpartspermillionbyvolumeorpoundspermillionBtuforgaseouspollutants.Theblankspacesare

forregulatedHazardousAirPollutantsforoptionalusebyPolkCo

untyinthefuture.

6. EstimateofActualEmissions‐Actualemissionsaretheactualrateofair

pollutionfromanemissionunitcalculated

usingtheemissionunit’sactualoperatinghours,productionrates,andtypesofmaterialsprocessed,storedor

combustedforthecalendaryear.Generale

quationforcalculatingactua

lemissionswithcontrolequipment:(Actual

Throughput)x(EmissionFactor)x(ControlEfficiency)x(conversionfactortotons)=tonsperyear

Page6In

structions:

This application is designed to provide the reviewer information on plant-wide total emissions and emissions from each source.

Total emissions are verified by checking emissions from each source and are used to classify the plant into the appropriate

categories for PSD, NSPS, etc. If your facility is a Title V facility, you may submit annual emissions inventory data in lieu of

this form if the inventory is current and contains all the information requested in this form. Additional information may be

requested.

Fillinyourcompany’slegalname.

2. Providetheemissionpoint(stackorvent)identificationnumber.Includetheemissionpointnumberofthesourceyou

areseekingapermitfor.

3. Providetheemissionunit(s)identificationnumber.

4. Provideabriefdescriptio

nofthesourceidentifiedin1.&2.

5. Providethepermitnumberforthesource,ifany.

6. Fill in the rate of potent

ial to emit orpermitted emission rate in tons per year for each pollutant. Potential to emit is

defined as uncontrolled emissions at maximumdesign or achievable cap

acity (whicheveris higher) and year‐round

contin

uousoperation (8760 hours peryear) if there are no federally‐enforceable permit limits on the source. If an

emissionpointhasbeenpermitted,thenthepermittedemissionrateintonsperyearisthepotentialtoemit.Ifthe

emissionpointwillhaveacontroldeviceorsomeotherlimitationsuchashoursormaterialusage,thiscanbeusedin

calculating pot

ential to emit. Proposed or existing permit limits may be considered to be potential to emit. The

followingareregulate

dpollutantswhichmustbeaccountedfor:PM:AllParticulateMatter(sameastotalsuspended

particulat

ematter),PM10:Particulatematterwithanaerodynamicdiameteroftenmicrons

orless,asmeasuredby

anEPA‐approvedreference method,PM2.5:Particulate matter with an  aerodynamicdiameter oftwoand onehalf

microns or less, as measured by an EPA‐ approved reference method, SO2: Sulfur Dioxid

e, NOx: Nitrogen Oxides,

VOCs:Photochemicallyreactivevolatileorganiccompoun

ds,CO:CarbonMonoxide,Lead(Pb),“Greenhousegases”‐

CarbonDioxide,Methane,NitrousOxide,SulphurHexafluoride,HydrofluoroCarbons(HFC),PerfluoroCarbons(PFC).

* CollectionofGreenhouseGas(GHG)EmissionsData‐StartingonJuly2,2007,constructionpermit



applicationsmust

includepotentialgreenhousegasemissionsfortheproject.Applicationsreceivedwithout



thisinformationwillbe

consideredincompleteandthepermit(s)cannotbeissueduntiltheinformationhas



beenreceived.Thefollowing

aretheGHGemissionsthatmustbeaccounted:

:Carbondioxide.

:Methane.

O:Nitrousoxide.Alsoknownasdinitrogenoxideordinitrogenmonoxideor

laughinggas.SF

:Sulfurhexafluoride.

HFC:Hydrofluorocarbons:SEETABLEA:COMMONGREENHOUSEGASES

PFC:Perfluorocarbons:SEETABLEA:COMMONGREENHOUSEGASES

.

7. Fillinthesumforeachpollutantforallemissionpoints(stacksorvents).

8. Fugitive

emissionsarethoseemissionswhichcannotreasonablybemadetopassthroughastackorventorequivalent

opening.Inso mecases,fugitive emissions mustbeincluded with apermit applicatio

n.Fugitiveemissions mustbe

includedifyourfacilityisoneofthe28name

dsourcecategoriesfoundinPSDrulesin40CFR52.521;ifyourfacilityis

subjecttoaNSPSstandardsasofAugust7,1980;ifyourfacilityissubjecttoaNESHAPstandardasofAu

gust7,1980;

orifyour facilityhasbeen determinedtobemajor forPSD,fugitive emissions,tothe extendquantifiable,mustbe

include

d in subsequent applications. Examples of fugitive emissions include coal piles, and unpaved roads. If your



facilityisnotsubjecttooneofthesecategories,youdonotneedtolistfugitiveemissions

.Foreachsourceoffugitive

emissions, assign a number to identify the source. This can be nay number, as long as it is difference from the

emissionpoint(stackorvent)numbersandconsistentwiththenumberssubmittedinotherpermitapplications,such

as Title V (if your facility submitted a Ti

tle V application). The number should also be consistent with othe

r

construction permit applications, and be consistent within this application. If you have more fugitive emission

sources than can fit on this form, attach a list to the form. Briefly describe the source, and provide the permit

numberifithasone.Fillth

erateofpotentialtoemitintonsperyearforeachpolluta

nt.

9. Fillinthesumofallfugitiveemissionsforeachpollutant.

10. Fillinthesumofthetotalplantemissionsforeachpollutant,includingemissionpointsandfugitivesources.

TABLEA:COMMONGR

EENHOUSEGASES

GAS CHEMICALFORMULA

Carbondioxide



Methane

NitrousOxide

Sulfurhexafluoride



Hydrofluorocarbons:

HFC‐23

CHF



HFC‐32

HFC‐41

HFC‐125

HFC‐134

CHF



HFC‐134a

HFC‐143

FCF

CHF

HFC‐143a

HFC‐152

FCH

HFC‐152a

HFC‐161

CHF

HFC‐227ea

HFC‐236cb

HFC‐236ea

CHFCF

FCF

CHF

CHFCF



HFC‐236fa

HFC‐245ca

FCF

CHF



HFC‐245fa

HFC‐265mfc

CHF



HFC‐365mfc



HFC‐43‐10mee

CHFCHFCF



Perfluorocarbons:

Perfluoromethane(PFC‐14)



Perfluoroethane(PFC‐116)



Perfluoropropane(PFC‐218)



Perfluorobutane(PFC‐3‐1‐10)

10

Perfluorocyclobutane(PFC‐318)

c‐C



Perfluoropentane(PFC‐4‐1‐12)

Nitro

enTrifluoride



Perfluorohexane(PFC‐5‐1‐14)

(PFC‐9‐1‐18)

Trifluorometh

lSul

hurPentafluoride

* SenateFile485definesagreenhousegasasbeingcarbondioxide,methane,nitrousoxide,hydrofluorocarbons,

perfluorocarbons,andsulfurhexafluoride.

* Thisisnotanallinclusivelist

andwillbeupdatedperiodically.

* ThechemicalformulaswereobtainedfromtheIntergovernmentalPanelonClimateChange(IPCC)WorkingGroup1:ThePhysical

BasisofClimateChange,Section2:ChangesinAtmosphericConstituentsandRadiactiveForcing

Thelinkisasfollows:http://ipcc‐wg1.ucar.edu/wg1/wg

1‐report.html(page84of106).

Supplementalformsinsupportofaconstructionpermitapplication:

BoilerForm(Form‐B)

EngineForm(Form‐E)

ModelingDetermination(Form‐M)

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.

PageIntentionallyLeftBlank

SupplementalInformationinsupportof aConstructionPermit

Application



BoilerForm(Form‐B)

BoilerDescription

EmissionPoint(EP)#

EmissionUnit(EU)#

EngineManufacturer

Model#

ModelYear

FuelType

RatedCapacity(MMBtu/hr)

BoilerSubcategory

(1)

CommenceConstructionDate

ReconstructionDate

(2)

ControlEquipmentDescription

(1)

Thesubcategoriesofboilersandprocessheaters,asdefinedin§ 63.7575are:

(a)

Pulverizedcoal/solidfossilfuelunits.

(b)

Stokersdesignedtoburncoal/solidfossilfuel.

(c)

Fluidizedbedunitsdesignedtoburncoal/solidfossilfuel.

(d)

Stokersdesignedtoburnbiomass/bio‐basedsolid.

(e)

Fluidizedbedunitsdesignedtoburnbiomass/bio‐basedsolid.

(f)

Suspensionburners/DutchOvensdesignedtoburnbiomass/bio‐basedsolid.

(g)

FuelCellsdesignedtoburnbiomass/bio‐basedsolid.

(h)

Hybridsuspension/grateburnersdesignedtoburnbiomass/bio‐basedsolid.

(i)

Unitsdesignedtoburnsolidfuel.

(j)

Unitsdesignedtoburnliquidfuel.

(k)

Unitsdesignedtoburnliquidfuelinnon‐continental Statesorterritories.

(l)

Unitsdesignedtoburnnaturalgas,refinerygasorothergas1fuels.

(m)

Unitsdesignedtoburngas2(other)gases.

(n)

Metalprocessfurnaces.

(o)

Limited‐useboilersandprocessheaters.

(2)

Amodificationisaphysicaloroperationalchangethatcanincreasetheemissionsofaregulatedair

pollutant.



Reconstructionisreplacingthecomponentsofanexistingengineandthecostofthereplacement

components



exceeds50%ofthecostofanewengine.See40CFR60.14and60.15forcompletedefinitions.

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SupplementalInformationinsupportof aConstructionPermitApplication



EngineForm(Form‐E)

(

1)

Datetheenginewasordered.

(2)

EmergencystationaryinternalcombustionengineisastationaryICEwhoseoperationislimitedto

emergency



situationsandrequiredtestingandmaintenance.ExamplesincludestationaryICEusedtoproduce

poserfor



criticalnetworksorequipment(includingpowersuppliedtoportionsofafacility)whenelectric

powerfromthe



localutility(orthenormalpowersource,ifthefacilityrunsonitsownpowerproduction)is

interrupted,or



stationaryIceusedtopumpwaterinthecaseoffireorflood,etc.StationarySIICEusedto

supplypowertoan



electricgridorthatsupplypoweraspartofafinancialarrangementwithanotherentity

arenotconsideredtobe



emergencyengines.

(3)

Aportableenginethatwillremainatallocationmorethan12monthsoraportableenginethatoperates



than3monthsperyearaspartofaseasonalsourcethatreturnstothesamelocationisconsidereda

stationary



engine.

(4)

Amodificationisaphysicaloroperationalchangethatcanincreasetheemissionsofaregulatedair

pollutant.



Reconstructionisreplacingthecomponentsofanexistingengineandthecostofthereplacement

components



exceeds50%ofthecostofthenewengine.See40CFR60.14and60.15foracomplete

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

2-Stroke

4-Stroke

Rich Burn

Lean Burn

Yes

PageIntentionallyLeftBlank

SupplementalInformationinsupportof aConstructionPermit

Application

NON‐PSDMODELINGDETERMINATION(FORM–M)

CompanyName:

OfficeUse:

AIRS#:



Permit#:



Energov



DISPERSIONMODELINGDETERMINATION

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.

This form reflects the Polk County Air Quality Division’s (AQD) Air Dispersion Modeling  Applicability Procedure for Non‐PSD construction

permit applications. Please check the appropriate box below depending on whether the flow chart indicates that dispersion modeling is

requiredornot.

Note:ALLprojectsmustincludeasiteplan;seesection“PLOTPLANREQUIREMENTS”forinstructions. Ascaledplotplanoftheentireplantis

required.Attachtheplotplan,labeledas"MI‐PP",withyourpermitapplication.

Note: Form M only applies to point source emissions and should not be applied to internally venting vol

ume sources. Internally vented

sourceswillbeaddressedonacase‐by‐casebasis.

DISPERSIONMODELINGANALYSISISNOTREQUIRED

Since the point source emissions in this application meet the criteria currently listed in the Air Dispersion Modeling Applicability

Procedure,itislikelythatmodeling isnotrequired.

ThereareuniquecircumstancesthattheAirDispersionModelingApplicabilityProceduredoesnotaddressthatmaytriggeramodeling

review.RecommendationsformodelingreviewsthatfalloutsideoftheAirDispersionModelingApplicabilityProcedurewillberev

iewed

byPolkCountyAQDmanagement.

DISPERSIONMODELINGANALYSISISREQUIRED

When dispersion modeling is required, the modeling  analysis is either conducted by the Polk County AQD or is submitted by the

applicantforPolkCountyAQDreviewasnotedbelow:

 All applicants have the option to prepare and submit a complete dispersion modeling analysis, subject to review by the Polk

CountyAQD.

 Formajorsourcesthathavepreviouslybeenmodeled,thePolkCountyAQDwillconductthemodeling analysisifresourcesallow.

Applicantswithextensivechangestotheirfacilitymayexpeditethemodelingreviewbysubmittingtheirownmodelinganalysis.

 For major sources that have not previously been modeled, the applicant must prepare and submit the dispersion modeling

analysis.



Fornon‐majorsources(minor),thePolkCountyAQDwill conducttheinitialdispersionmodelingasa  servicetominorsourceswhena

modelinganalysishasnotbeensubmittedbytheapplicant.

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.

Yes

NON‐PSDMODELINGDETERMINATION(FORM–M)Continued:

 Pass

Pollutant Significant

Emission

Rate

NationalAmb

ientAirQualityStandard

(µg/m

)

SignificantImpac

tLevel(SIL)

(µg/m

)

1‐hour 3‐hour 8‐hour 24‐hour Annual 1‐hour 3‐hour 8‐hour 24‐hour Annual

PM10 3.42lb/hr 150 5

2.5

2.28lb/hr 35 15 1.2 0.3



9.13lb/hr 188 100 7.5 1

*

9.13lb/hr 196 1,300 365 80 7.9 25 5 1

CO 22.8lb/hr 40,000 10,000 2,000 500

For1‐hourSO

:nodispersionmodelingiscurrentlyrequiredforminorprojects.Ambientairimpactevaluationwillberequiredinthefuture



State

ImplementationPlanrevision.

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?

Yes

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Completed 1 July 2020

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