EIQ Form 1.0 (MO780-1431) "Emissions Inventory Questionnaire (Eiq) General Plant Information" - Missouri

What Is EIQ Form 1.0 (MO780-1431)?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on November 1, 2014;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • 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 EIQ Form 1.0 (MO780-1431) by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
AIR POLLUTION CONTROL PROGRAM
EMISSIONS INVENTORY QUESTIONNAIRE (EIQ)
FORM 1.0 GENERAL PLANT INFORMATION
Request Confidentiality – Check this box only if you intend to formally request confidentiality (see instructions online).
FACILITY NAME
FIPS COUNTY NO.
PLANT NO.
YEAR OF DATA
FACILITY STREET ADDRESS
COUNTY NAME
CITY
ZIP CODE +4
TELEPHONE NUMBER WITH AREA CODE EXT.
FAX NUMBER WITH AREA CODE
FACILITY MAILING ADDRESS
CITY
STATE
ZIP CODE +4
FACILITY CONTACT NAME
FACILITY CONTACT TITLE
FACILITY CONTACT EMAIL
WHERE TO SEND EIQ IN FUTURE (CHECK ONE)
Facility Mailing Address
Parent Company Mailing Address
PRODUCT/PRINCIPAL ACTIVITY
SIC
NAICS
NUMBER OF EMPLOYEES
LATITUDE
LONGITUDE
UTM COORDINATES
ZONE
EASTING (M)
NORTHING (M)
ACC (M)
HORIZONTAL DATUM (CHECK ONE)
DEGREES
NAD27
WGS84
MINUTES
NAD83
SECONDS
PARENT COMPANY NAME
TELEPHONE NUMBER WITH AREA CODE EXT.
FAX NUMBER WITH AREA CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE +4
CONTACT PERSON NAME
CONTACT PERSON TITLE
CONTACT PERSON EMAIL
COUNTRY
TOTAL PLANT EMISSIONS FROM FORM 3.0 (TONS PER YEAR)
VOC
CO
LEAD
HAPs
PM
PM
SO
NO
NH
10
X
X
3
2.5
The undersigned hereby certifies that they have personally examined and are familiar with the information and statements contained
herein and further certifies that they believe this information and statements to be true, accurate and complete. The undersigned
certifies that knowingly making a false statement or misrepresenting the facts presented in this document is a violation of state law.
PRINT NAME OF PERSON COMPLETING FORM
TITLE
PAYMENT AMOUNT
SIGNATURE
DATE
CHECK/AUTH. NO.
PRINT NAME OF AUTHORIZED COMPANY REPRESENTATIVE
TITLE
PAYMENT DATE
SIGNATURE
DATE
CONTACT INFORMATION
OFFICE USE ONLY
LOGGED IN BY
DATE
Missouri Department of Natural Resources
Air Pollution Control Program
1659 E. Elm St., P.O. Box 176
Jefferson City, MO 65101
573-751-4817
eiq@dnr.mo.gov
MO 780-1431 (11-14)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
AIR POLLUTION CONTROL PROGRAM
EMISSIONS INVENTORY QUESTIONNAIRE (EIQ)
FORM 1.0 GENERAL PLANT INFORMATION
Request Confidentiality – Check this box only if you intend to formally request confidentiality (see instructions online).
FACILITY NAME
FIPS COUNTY NO.
PLANT NO.
YEAR OF DATA
FACILITY STREET ADDRESS
COUNTY NAME
CITY
ZIP CODE +4
TELEPHONE NUMBER WITH AREA CODE EXT.
FAX NUMBER WITH AREA CODE
FACILITY MAILING ADDRESS
CITY
STATE
ZIP CODE +4
FACILITY CONTACT NAME
FACILITY CONTACT TITLE
FACILITY CONTACT EMAIL
WHERE TO SEND EIQ IN FUTURE (CHECK ONE)
Facility Mailing Address
Parent Company Mailing Address
PRODUCT/PRINCIPAL ACTIVITY
SIC
NAICS
NUMBER OF EMPLOYEES
LATITUDE
LONGITUDE
UTM COORDINATES
ZONE
EASTING (M)
NORTHING (M)
ACC (M)
HORIZONTAL DATUM (CHECK ONE)
DEGREES
NAD27
WGS84
MINUTES
NAD83
SECONDS
PARENT COMPANY NAME
TELEPHONE NUMBER WITH AREA CODE EXT.
FAX NUMBER WITH AREA CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE +4
CONTACT PERSON NAME
CONTACT PERSON TITLE
CONTACT PERSON EMAIL
COUNTRY
TOTAL PLANT EMISSIONS FROM FORM 3.0 (TONS PER YEAR)
VOC
CO
LEAD
HAPs
PM
PM
SO
NO
NH
10
X
X
3
2.5
The undersigned hereby certifies that they have personally examined and are familiar with the information and statements contained
herein and further certifies that they believe this information and statements to be true, accurate and complete. The undersigned
certifies that knowingly making a false statement or misrepresenting the facts presented in this document is a violation of state law.
PRINT NAME OF PERSON COMPLETING FORM
TITLE
PAYMENT AMOUNT
SIGNATURE
DATE
CHECK/AUTH. NO.
PRINT NAME OF AUTHORIZED COMPANY REPRESENTATIVE
TITLE
PAYMENT DATE
SIGNATURE
DATE
CONTACT INFORMATION
OFFICE USE ONLY
LOGGED IN BY
DATE
Missouri Department of Natural Resources
Air Pollution Control Program
1659 E. Elm St., P.O. Box 176
Jefferson City, MO 65101
573-751-4817
eiq@dnr.mo.gov
MO 780-1431 (11-14)