Form SFN52858 "Permit Application for Title V Permit to Operate" - North Dakota

What Is Form SFN52858?

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

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the North Dakota Department of Health;
  • 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 Form SFN52858 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN52858 "Permit Application for Title V Permit to Operate" - North Dakota

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PERMIT APPLICATION FOR TITLE V PERMIT TO OPERATE
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 52858 (01-16)
SECTION A - FACILITY INFORMATION
Name of Firm or Organization
Responsible Person
Title
Telephone Number
E-mail Address
Mailing Address (Street & Number)
City
State
ZIP Code
Contact Person for Air Pollution Matters
Title
Telephone Number
E-mail Address
Mailing Address (Street & Number)
City
State
ZIP Code
Facility Name
Facility Address (Street & Number)
City
State
ZIP Code
County
Latitude (decimal degrees)
Longitude (decimal degrees)
Legal Description of Facility Site
Land Area at Facility Site
MSL Elevation at Facility
¼
¼, or
½
½,
Acres (or)
Sq. Ft.
Section
Twp.
Range
SECTION B – GENERAL NATURE OF BUSINESS
North American Industry
Standard Industrial
Describe Nature of Business
Classification System Code (NAICS)
Classification Code (SIC)
SECTION C – GENERAL PERMIT INFORMATION
Type of Permit to Operate?
Initial
Minor Modification
Significant Modification
If application is for renewal or revision of an existing Title V permit, please provide the following data:
Current Permit to Operate
Current Permit to Operate Expiration Date:
Number:
Renewal:
Revision: _______
PERMIT APPLICATION FOR TITLE V PERMIT TO OPERATE
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 52858 (01-16)
SECTION A - FACILITY INFORMATION
Name of Firm or Organization
Responsible Person
Title
Telephone Number
E-mail Address
Mailing Address (Street & Number)
City
State
ZIP Code
Contact Person for Air Pollution Matters
Title
Telephone Number
E-mail Address
Mailing Address (Street & Number)
City
State
ZIP Code
Facility Name
Facility Address (Street & Number)
City
State
ZIP Code
County
Latitude (decimal degrees)
Longitude (decimal degrees)
Legal Description of Facility Site
Land Area at Facility Site
MSL Elevation at Facility
¼
¼, or
½
½,
Acres (or)
Sq. Ft.
Section
Twp.
Range
SECTION B – GENERAL NATURE OF BUSINESS
North American Industry
Standard Industrial
Describe Nature of Business
Classification System Code (NAICS)
Classification Code (SIC)
SECTION C – GENERAL PERMIT INFORMATION
Type of Permit to Operate?
Initial
Minor Modification
Significant Modification
If application is for renewal or revision of an existing Title V permit, please provide the following data:
Current Permit to Operate
Current Permit to Operate Expiration Date:
Number:
Renewal:
Revision: _______
SFN 52858 (01-16) Page 2
SECTION D – MINOR PERMIT MODIFICATION
Affected Emission Unit(s):
Description of Proposed Change:
Applicable Requirements (NSPS, PSD, etc.):
Net Effect on Source Emissions
Emission Unit(s):
Facility:
Are you requesting that minor permit modification procedures be used in accordance with NDAC 33-15-14-
06.e(1)(a)?
Yes
No
SECTION E – SOURCE IDENTIFICATION AND CATEGORY OF EACH SOURCE
INCLUDED ON THIS PERMIT APPLICATION
Your
Emission
Emission
Unit
Unit
Number
Description
PTC Number
Explain if Other
Add additional pages if necessary
SFN 52858 (01-16) Page 3
SECTION F1 – IDENTIFICATION OF AIR CONTAMINANTS
Check all which are emitted in measurable quantities into the atmosphere from any operation at facility
Arsenic
Chlorine Compounds
Sulfur Compounds
Radioisotopes
Asbestos
Chromium Compounds
Hydrogen Sulfide
Visible Emissions
Beryllium
Fluoride Compounds
Odors
Particulates (specify)
Cadmium
Volatile Organic Compounds
Carbon Monoxide
Dust
Lead
Other Organic Compounds
Nitrogen Compounds
Silica
Mercury
Greenhouse Gases (CO
e)
Pesticides
Other (specify)
2
List Specific Compounds:
SECTION F2 – IDENTIFICATION OF AIR CONTAMINANTS
Has emission unit testing been done at the facility?
Yes
No
Last Date when a
Regulation requiring frequency (NSPS,
Emission
If Program is Continuous, Give
Testing Program was
MACT, Permit Requirement-list permit
Unit No.
Approximate Testing Frequency
Completed
number)
Add additional pages if necessary
SECTION G1 – ADDITIONAL FORMS
Indicate which of the following forms are attached and made part of the application
Flexible Permits
Emission Unit Information
61007
(SFN 61006)
(SFN
)
Compliance Schedule and Plan
Potential To Emit Table
(SFN
)
61008
SECTION G2 – OTHER ATTACHMENTS INCLUDED AS PART OF THIS APPLICATION
1.
4.
2.
5.
3.
6.
I, the undersigned applicant, am fully aware that statements made in this application and the attached exhibits and
statements constitute the application for Permit to Operate Air Contaminant sources from the North Dakota
Department of Health and certify that the information in this application is true, correct and complete to the best of my
knowledge and belief. Further, I agree to comply with the provisions of Chapter 23-25 of the North Dakota Century
Code and all rules and regulations of the Department, or revisions thereof.
I also understand the permit is
nontransferable and, if granted a permit, I will promptly notify the Department upon sale or legal transfer of this
permitted establishment.
Signature of Applicant
Date
SFN 52858 (01-16) Page 4
INSTRUCTIONS
These instructions are intended to assist permit applicants in the completion of the enclosed forms with the degree of
accuracy and detail necessary to allow the determination of whether to grant or deny a permit to operate an air
contaminant source or modification.
All information included in the application, including maximum estimated emission rates, will be used to
make the above determination. The information that is supplied in the application may be used to establish
permit conditions.
The emission rates provided should be based on the most credible data available.
Although AP-42 provides general information, it should not be solely relied on to develop emission rates.
Other sources of information that accurately represent the actual conditions that the emission unit will be
operated under, such as actual test data or manufacturer’s data, may be preferable.
For any air contaminant source or modification described in SFN 52858, SFN 61006 must also be must be completed
and attached for each emission unit. For the facility’s compliance schedule, SFN 61008 must be completed and
submitted. If the facility requests a flexible permit SFN 61007, must be completed and submitted.
Those existing sources of air contaminants which are proven by the applicant to be designed or controlled so as to
operate without emitting air contaminants in violation of air pollution rules and regulations will be granted a permit to
operate.
Certain sizes and types of existing or new sources are exempted from the requirement to obtain a permit to continue
operating or to construct. These sizes are specified in the instruction sheets for the relevant permit application forms
or can be obtained by contacting the Department.
Any information included on the forms, other than emission data, that would divulge production or sales figures or
methods, processes or production unique to such person or would otherwise tend to affect adversely the competitive
position of such person by revealing trade secrets should be noted by inserting the word "confidential" in the margin
next to the appropriate item.
Any information, other than production figures, that is requested to be kept in
confidence must be justified by a written statement setting forth the reasons for the request. All information not
marked confidential will be available for public inspection.
These forms are intended to inform permit applicants of the type of information required in order that a permit to
operate or construct be granted. It is not possible to design forms which are ideally suited to every conceivable
operation. Permit applicants are encouraged to submit additional supplementary material when it is felt that the
completion of these forms does not provide an adequate explanation of the operation.
It will be necessary to refer to the North Dakota Air Pollution Control Rules (Article 33-15 NDAC; online at
www.legis.nd.gov/information/acdata/html/33-15.html), especially those parts which deal with the permit system and
those chapters which specify emission limitations for each air contaminant, in order to satisfactorily complete a permit
application. Electronic copies of air pollution control permit application forms are available online at
www.ndhealth.gov/AQ/forms.aspx. Paper copies of all forms, as well as the rules, are available on request. To cover
the costs of printing and postage, the charge for a copy of the North Dakota Air Pollution Control Rules is $15.00.
Applicants should contact the Department prior to preparation and submittal of an application to determine what
additional information will be required for a particular source or modification and the method to be used in performing
the analyses.
SEND COMPLETED APPLICATION AND ALL ATTACHMENTS TO:
North Dakota Department of Health
Division of Air Quality
918 E Divide Ave., 2nd Floor
Bismarck, ND 58501-1947
(701) 328-5188
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