Form SFN52737 "Title V Semi-annual Monitoring Report" - North Dakota

What Is Form SFN52737?

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 December 1, 2005;
  • 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 printable version of Form SFN52737 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 SFN52737 "Title V Semi-annual Monitoring Report" - North Dakota

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TITLE V SEMI-ANNUAL MONITORING REPORT
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 52737 (12-05)
Name of Company:
Facility Location:
Reporting Period:
Permit No.:
Person to Contact Regarding Questions:
Mailing Address:
Phone No.:
Complete Parts 1 and 2 below for permit deviations (use additional sheets if
necessary).
For
permit
deviations
previously
reported
in
excess
emissions
(quarterly
or
semi-annual)
report(s),
make
reference
to
the
excess
emissions
(quarterly or semi-annual) report(s) in Parts 1 and 2 below.
PART 1.
Description of Permit Deviation(s) from Monitoring Requirement(s)
(As outlined in permit condition entitled “Monitoring Requirements and
Conditions”)
□ None
□ As indicated below
Date of
Emission
Pollutant/
Description of the Monitoring Downtime, Length of
Missed
Unit ID
Parameter
Monitoring
Time and
Data
No.
Monitored
Method
Corrective Action Taken
PART 2.
Description of Permit Deviation(s) from Emission Limit(s)/Parameter(s)
(As outlined in permit condition entitled “Emission Unit(s) Limits”)
□ None
□ As indicated below
Emission
Applicable
Date of
Unit ID
Permit
Description of the Deviation, Length of Time
Deviation
No.
Condition
and Corrective Action Taken
Send copy of report to:
ND Department of Health
Division of Air Quality
918 E Divide, 2nd Floor
Bismarck, ND 58501-1947
TITLE V SEMI-ANNUAL MONITORING REPORT
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF AIR QUALITY
SFN 52737 (12-05)
Name of Company:
Facility Location:
Reporting Period:
Permit No.:
Person to Contact Regarding Questions:
Mailing Address:
Phone No.:
Complete Parts 1 and 2 below for permit deviations (use additional sheets if
necessary).
For
permit
deviations
previously
reported
in
excess
emissions
(quarterly
or
semi-annual)
report(s),
make
reference
to
the
excess
emissions
(quarterly or semi-annual) report(s) in Parts 1 and 2 below.
PART 1.
Description of Permit Deviation(s) from Monitoring Requirement(s)
(As outlined in permit condition entitled “Monitoring Requirements and
Conditions”)
□ None
□ As indicated below
Date of
Emission
Pollutant/
Description of the Monitoring Downtime, Length of
Missed
Unit ID
Parameter
Monitoring
Time and
Data
No.
Monitored
Method
Corrective Action Taken
PART 2.
Description of Permit Deviation(s) from Emission Limit(s)/Parameter(s)
(As outlined in permit condition entitled “Emission Unit(s) Limits”)
□ None
□ As indicated below
Emission
Applicable
Date of
Unit ID
Permit
Description of the Deviation, Length of Time
Deviation
No.
Condition
and Corrective Action Taken
Send copy of report to:
ND Department of Health
Division of Air Quality
918 E Divide, 2nd Floor
Bismarck, ND 58501-1947
If
your
facility
is
subject
to
Compliance
Assurance
Monitoring
(CAM),
Complete
Part
3
for
CAM
Reporting
of
Excursions
or
Exceedances
(use
additional sheets if necessary).
Part 3.
Description of CAM Excursion(s)* or Exceedances(s)**
None
As indicated below
Pollutant
Monitored/
Date of
Emission
Emission
Excursion
Unit ID
Limit
Indicator Range
Description of CAM Excursion or
or
No./Control
(e.g. Part./
(e.g. 2-4 in.
Exceedance, Length of Time and Corrective
Exceedance
Device
200 lb/hr
pressure drop)
Action Taken
*
Excursion is a departure from an indicator range.
**
Exceedance is a condition that is detected by monitoring that provides
data in terms of an emission limit and that indicates that emissions are
greater than the emission limit.
Note (CAM Monitoring Guideline): If the process is operating, monitoring data
must be recorded.
Even though excursions or exceedances during startup,
shutdown,
or
malfunctions
of
the
process
may
not
be
violations
of
the
emission limits, the monitoring system must be operating and recording during
these periods of operation just as during “normal” process operation, and
excursions or exceedances must be reported.
PART 4.
Other Permit Deviations (not reported in Parts 1 and 2)
YES
NO
N/A
Does the Emission Unit Identification Section of your permit require any
changes to accurately reflect all existing source units at the facility?
If yes, attach appropriate information/date.
Have any changes occurred to the air pollution control equipment or to the
emission monitoring equipment at the facility which are not correctly
listed on the permit?
If yes, attach explanation.
Have any permit deviations occurred to the Fuel Restrictions and/or
Operation Limitations listed in the permit?
If yes, attach explanation.
Have any permit deviations occurred to the Recordkeeping and/or Reporting
Requirements listed in the permit?
If yes, attach explanation.
Have any permit deviations occurred to the Facility Wide Operating
Conditions listed in the permit?
If yes, attach explanation.
Have any permit deviations occurred to the General Conditions listed in
the permit?
If yes, attach explanation.
Have any permit deviations occurred to the State Enforcement Only
Conditions listed in the permit?
If yes, attach explanation.
Were there any other permit deviations not addressed above?
If yes, attach explanation.
PART 5.
Excess Emissions Report(s)
Have excess emissions report(s) (quarterly or semi-annual) been submitted to
the Department for the period covered by this semi-annual monitoring report?
☐ No
Yes: □ Previously Submitted
If no, attach explanation
☐ Attached with this report
☐ Not Required
PART 6.
Portable Analyzer and Stack Testing Data
The Department requires that test reports be submitted within 60 days for
emission units where the method of compliance monitoring is demonstrated by
either an EPA Reference Method, a portable analyzer test, or an equivalent EPA
Reference Method.
Test results have been submitted as required.
Test results have not been submitted - Explain:
No testing was required.
PART 7.
Certification of Truth, Accuracy and Completeness
I
certify
that,
based
on
information
and
belief
formed
after
reasonable
inquiry, the statements and information contained in this report are true,
accurate and complete.
Print name of Responsible Official
Title
Signature of Responsible Official
Date
Page of 3