State Form 51864 (CD-04) "Oaq Compliance Determination Application - Compliance Schedule and Certification" - Indiana

What Is State Form 51864 (CD-04)?

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

Form Details:

  • Released on January 1, 2010;
  • The latest edition provided by the Indiana 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 fillable version of State Form 51864 (CD-04) by clicking the link below or browse more documents and templates provided by the Indiana Department of Environmental Management.

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Download State Form 51864 (CD-04) "Oaq Compliance Determination Application - Compliance Schedule and Certification" - Indiana

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OAQ COMPLIANCE DETERMINATION APPLICATION
IDEM – Office of Air Quality – Permits Branch
CD-04: Compliance Schedule and Certification
100 N. Senate Avenue, MC 61-53 Room 1003
Indianapolis, IN 46204-2251
State Form 51864 (R2 / 1-10)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Telephone: (317) 233-0178 or
Toll Free: 1-800-451-6027 x30178 (within Indiana)
Facsimile Number: (317) 232-6749
www.IN.gov/idem
NOTES:
The purpose of CD-04 is to provide a schedule of for compliance certification submittals, a certification of the source’s compliance
status with all applicable requirements, and a compliance schedule that details the measures a source will use to address non-
compliance.
Complete this form once per application (not once for each emissions unit) with respect to all applicable requirements at the
source.
This is required form for each initial Title V permit application as well as each modification and every renewal.
Detailed instructions for this form are available on the Air Permit Application Forms website.
All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality.
Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out
in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your information becoming a public record, available
for any one to inspect and photocopy.
PART A: Source Identification and Compliance Schedule
Part A identifies the permitted source and the permit term compliance certification schedule.
1. Source Name:
2. Source ID:
3. Permit Term Compliance Certification Schedule
Date of first certification submittal:
Frequency of future submittals:
PART B: Risk Management Plan
Part B indicates whether sources subject to section 112(r), Accidental Release Prevention, are complying with the
requirement to submit a Risk Management Plan (RMP).
4. Statement of Applicability / Non-Applicability: Indicate whether the source is subject to Section 112(r) and the
requirement to submit and RMP.
Source is subject to Section 112(r) and a Risk Management Plan (RMP) is required.
Source is not subject to Section 112(r) and a Risk Management Plan (RMP) is not required.
RMP Submittal Information: Indicate when the RMP was submitted to each of the following agencies. If the RMP has
not yet been submitted to any of the listed agencies, indicate the date when the RMP will be mailed to that agency. If the
RMP for IDEM is attached to this application, please write “attached” in the Date Submitted column.
5. Agency Name
6. Date Submitted
7. Expected Submittal Date
Chemical Safety and Hazard Investigation Board (CSHIB)
United States Environmental Protection Agency (U.S. EPA)
Indiana Department of Environmental Management (IDEM)
Local Agency responsible for permitting:
8. EPA Facility Identifier:
Continued on Next Page
Page 1 of 2
Reset Form
OAQ COMPLIANCE DETERMINATION APPLICATION
IDEM – Office of Air Quality – Permits Branch
CD-04: Compliance Schedule and Certification
100 N. Senate Avenue, MC 61-53 Room 1003
Indianapolis, IN 46204-2251
State Form 51864 (R2 / 1-10)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Telephone: (317) 233-0178 or
Toll Free: 1-800-451-6027 x30178 (within Indiana)
Facsimile Number: (317) 232-6749
www.IN.gov/idem
NOTES:
The purpose of CD-04 is to provide a schedule of for compliance certification submittals, a certification of the source’s compliance
status with all applicable requirements, and a compliance schedule that details the measures a source will use to address non-
compliance.
Complete this form once per application (not once for each emissions unit) with respect to all applicable requirements at the
source.
This is required form for each initial Title V permit application as well as each modification and every renewal.
Detailed instructions for this form are available on the Air Permit Application Forms website.
All information submitted to IDEM will be made available to the public unless it is submitted under a claim of confidentiality.
Claims of confidentiality must be made at the time the information is submitted to IDEM, and must follow the requirements set out
in 326 IAC 17.1-4-1. Failure to follow these requirements exactly will result in your information becoming a public record, available
for any one to inspect and photocopy.
PART A: Source Identification and Compliance Schedule
Part A identifies the permitted source and the permit term compliance certification schedule.
1. Source Name:
2. Source ID:
3. Permit Term Compliance Certification Schedule
Date of first certification submittal:
Frequency of future submittals:
PART B: Risk Management Plan
Part B indicates whether sources subject to section 112(r), Accidental Release Prevention, are complying with the
requirement to submit a Risk Management Plan (RMP).
4. Statement of Applicability / Non-Applicability: Indicate whether the source is subject to Section 112(r) and the
requirement to submit and RMP.
Source is subject to Section 112(r) and a Risk Management Plan (RMP) is required.
Source is not subject to Section 112(r) and a Risk Management Plan (RMP) is not required.
RMP Submittal Information: Indicate when the RMP was submitted to each of the following agencies. If the RMP has
not yet been submitted to any of the listed agencies, indicate the date when the RMP will be mailed to that agency. If the
RMP for IDEM is attached to this application, please write “attached” in the Date Submitted column.
5. Agency Name
6. Date Submitted
7. Expected Submittal Date
Chemical Safety and Hazard Investigation Board (CSHIB)
United States Environmental Protection Agency (U.S. EPA)
Indiana Department of Environmental Management (IDEM)
Local Agency responsible for permitting:
8. EPA Facility Identifier:
Continued on Next Page
Page 1 of 2
Indiana Department Of Environmental Management
Compliance Certification
Office Of Air Quality
FORM CD-04
State Form 51864 (R2 / 1-10)
Page 2 of 2
PART C: Certification of Source Compliance Status
Part C states whether the source is or is not in full compliance with all applicable requirements and to identify corrective
actions to be taken in cases of noncompliance.
9. Check the Most Accurate Statement.
The source described in this air pollution control permit application is fully in compliance with all applicable
requirements and will continue to comply with those requirements.
FORM CD-01 includes new requirements that apply or will apply to the emissions unit during the term of the
permit. The source will meet such requirements on a timely basis.
The source described in this air pollution control permit application is fully in compliance with all applicable
requirements, except for the emissions unit(s) listed below. Compliance will be achieved according to the
schedule identified below.
10. Unit ID
11. Applicable Requirement
12. Corrective Action
13. Deadline
14. Progress Reports
Start Date
Frequency
15. Signature of Responsible Official
I certify that, based on information and belief formed after reasonable inquiry, the statements
and information presented are true, accurate and complete.
Name (typed)
Title
Signature
Date
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