ADEM Form 436 "Perc Dry Cleaner Status Update" - Alabama

What Is ADEM Form 436?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2012;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 436 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 436 "Perc Dry Cleaner Status Update" - Alabama

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PERC DRY CLEANER STATUS UPDATE
1. Print or type the following information for EACH separately located dry cleaning
facility. The owner of more than one facility should fill out a separate form for
EACH facility. (Make additional copies of this form, if needed).
Owner/Operator ____________________________________________________
Company Name ____________________________________________________
Mailing Address ____________________________________________________
Physical Address ____________________________________________________
City ____________________State___________Zip______County____________
Phone Number ______________________________________________________
2. Initial Submission of Questionnaire
Updated Submission of Questionnaire
3. Check the box below if:
Your dry cleaner is a Pick-up Store.
Your dry cleaning facility has only coin-operated dry cleaning machines that are
operated by the customers.
Your dry cleaning plant closed effective _________(date).
If you checked any box above, you may STOP HERE and return the
form to:
ADEM-Air Division
P. O. Box 301463
Montgomery, Al 36130-1463
4. Write in the total volume of perchloroethylene (PERC) purchased for ALL of the
machines at the dry cleaning plant over the past 12 months. If your facility is new
and has not operated an entire year, please estimate how much PERC will be
purchased in the next 12 months:
_____Gallons (Actual or Estimated)
ADEM Form 436 11/12 m1
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PERC DRY CLEANER STATUS UPDATE
1. Print or type the following information for EACH separately located dry cleaning
facility. The owner of more than one facility should fill out a separate form for
EACH facility. (Make additional copies of this form, if needed).
Owner/Operator ____________________________________________________
Company Name ____________________________________________________
Mailing Address ____________________________________________________
Physical Address ____________________________________________________
City ____________________State___________Zip______County____________
Phone Number ______________________________________________________
2. Initial Submission of Questionnaire
Updated Submission of Questionnaire
3. Check the box below if:
Your dry cleaner is a Pick-up Store.
Your dry cleaning facility has only coin-operated dry cleaning machines that are
operated by the customers.
Your dry cleaning plant closed effective _________(date).
If you checked any box above, you may STOP HERE and return the
form to:
ADEM-Air Division
P. O. Box 301463
Montgomery, Al 36130-1463
4. Write in the total volume of perchloroethylene (PERC) purchased for ALL of the
machines at the dry cleaning plant over the past 12 months. If your facility is new
and has not operated an entire year, please estimate how much PERC will be
purchased in the next 12 months:
_____Gallons (Actual or Estimated)
ADEM Form 436 11/12 m1
Page 1 of 3
5. Indicate the number of machines of each type that is located at your facility:
______Dry-to-Dry
_________Transfer
6. Are records of perceptible leaks, parts ordered, repairs, refrigerated condenser
temperature monitoring, PERC purchases, etc., being kept?
Yes
No
(If no is checked, these records are a requirement. Your facility should begin keeping
these records. They should be kept for five years and be readily available for
inspection).
7. Are you using the 20__ Dry Cleaner Compliance Calendar for recordkeeping?
Yes
No
8. Provide the following information for EACH MACHINE at your plant. If you have
more than 4 machines at your plant, make additional copies of this form.
Machine 1
Machine 2
Machine 3
Machine 4
Machine Type
Dry-to-Dry
Dry-to-Dry
Dry-to-Dry
Dry-to-Dry
(Circle one)
Transfer
Transfer
Transfer
Transfer
Date Machine
was installed
Control Device
(refrigerated
condenser or
carbon
adsorber)
Date Control
Device was
installed
9. If there has been a change in ownership at this facility in the past 12 months, please
indicate below.
____________________________
___________________________
Name
Date
10. Has there been a change from PERC to another cleaning agent?
Yes
No
If so, indicate the type of cleaning agent and date of changeover. _______________
ADEM Form 436 11/12 m1
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11. Print or type the name and title of the Responsible Official for the dry cleaning plant:
Name
Title
Signature
Date
Please return this form to:
ADEM-Air Division, P. O. Box 301463, Montgomery, Al 36130-1463
ADEM Form 436 11/12 m1
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