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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‐Constr

uctionPermitApplication

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



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



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‐Constr

uctionPermitApplication

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(tpy)

METHANE(t

py)

NITROUSOXI

DE(tpy)

SULFURHEX

AFLUORIDE(lbs/yr)

HYDROFLUOROCARBONS(l

bs/yr)

PERFLUOROCARBONS(L

BS/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.

structions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. Simpl

y stating that “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build

ingswithin200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co

ncrete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fu

gitive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:

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.

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.



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



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 vo

lume 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Applicabili

tyProcedurewillbereviewed

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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