Form APG-D "Notice of Intent to Decommission Stage Ii Controls and Decommission Plan Form" - Louisville, Kentucky

What Is Form APG-D?

This is a legal form that was released by the Air Pollution Control District - Louisville, Kentucky - a government authority operating within Kentucky. The form may be used strictly within Louisville. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the Air Pollution Control District - Louisville, Kentucky;
  • 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 APG-D by clicking the link below or browse more documents and templates provided by the Air Pollution Control District - Louisville, Kentucky.

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Download Form APG-D "Notice of Intent to Decommission Stage Ii Controls and Decommission Plan Form" - Louisville, Kentucky

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Deliver application to:
Louisville Metro Air Pollution Control District
701 West Ormsby Avenue
Suite 303
Louisville, KY 40204
NOTICE OF INTENT TO DECOMMISSION STAGE II
CONTROLS AND DECOMMISSION PLAN FORM
(502) 574-6000
FAX: (502) 574-5137
Form APG-D
www.louisvilleky.gov/apcd
airpermits@louisvilleky.gov
Section 1
Facility Information
Facility name:
Plant ID:
Facility address:
City:
ZIP + 4:
KY Secretary of State Organization number:
Same as Owner
Owner:
Operator:
Phone:
Email:
Section 2
Decommissioning Information
Date of Decommissioning:
Time of Decommissioning:
a.m.
p.m.
Decommissioning Contractor:
Address:
Phone:
City, State, ZIP:
Email:
Mobile Phone:
Section 3
Decommissioning Plan
A. Has a description or diagram of the Stage II vapor recovery system that is presently installed, including the number of
dispensers subject to decommissioning, been attached?
B Has a description or diagram of how the Stage II vapor recovery system will be decommissioned, including applicable
forms, tables, check lists, diagrams, materials lists, tests that will be performed, etc., been attached?
C. Has a description or diagram of the gasoline delivery system after decommissioning been attached?
D. Have arrangements been made to make all necessary repairs or install all necessary lock-outs and “Out of Service” tags in
the event decommissioning cannot be completed, including required testing, within 60 days of commencement?
Responsible Official Certification
The “Responsible Official” is the person in charge of a principal business function, or other person who performs similar policy
or decision-making functions for the corporation, or a duly authorized representative of that person if the representative is
responsible for the overall operation of one or more manufacturing, production, or operating facilities applying for or subject to
a permit. See District regulation 1.02, section 1.71 for a complete, detailed definition of Responsible Official.
Based on information and belief formed after reasonable inquiry, I certify that the statements and information in this
document and all associated attachments are true, accurate, and complete.
BY:
Typed or Printed Name of Signatory
Date
Authorized Signature
Title of Signatory
April 2016
Deliver application to:
Louisville Metro Air Pollution Control District
701 West Ormsby Avenue
Suite 303
Louisville, KY 40204
NOTICE OF INTENT TO DECOMMISSION STAGE II
CONTROLS AND DECOMMISSION PLAN FORM
(502) 574-6000
FAX: (502) 574-5137
Form APG-D
www.louisvilleky.gov/apcd
airpermits@louisvilleky.gov
Section 1
Facility Information
Facility name:
Plant ID:
Facility address:
City:
ZIP + 4:
KY Secretary of State Organization number:
Same as Owner
Owner:
Operator:
Phone:
Email:
Section 2
Decommissioning Information
Date of Decommissioning:
Time of Decommissioning:
a.m.
p.m.
Decommissioning Contractor:
Address:
Phone:
City, State, ZIP:
Email:
Mobile Phone:
Section 3
Decommissioning Plan
A. Has a description or diagram of the Stage II vapor recovery system that is presently installed, including the number of
dispensers subject to decommissioning, been attached?
B Has a description or diagram of how the Stage II vapor recovery system will be decommissioned, including applicable
forms, tables, check lists, diagrams, materials lists, tests that will be performed, etc., been attached?
C. Has a description or diagram of the gasoline delivery system after decommissioning been attached?
D. Have arrangements been made to make all necessary repairs or install all necessary lock-outs and “Out of Service” tags in
the event decommissioning cannot be completed, including required testing, within 60 days of commencement?
Responsible Official Certification
The “Responsible Official” is the person in charge of a principal business function, or other person who performs similar policy
or decision-making functions for the corporation, or a duly authorized representative of that person if the representative is
responsible for the overall operation of one or more manufacturing, production, or operating facilities applying for or subject to
a permit. See District regulation 1.02, section 1.71 for a complete, detailed definition of Responsible Official.
Based on information and belief formed after reasonable inquiry, I certify that the statements and information in this
document and all associated attachments are true, accurate, and complete.
BY:
Typed or Printed Name of Signatory
Date
Authorized Signature
Title of Signatory
April 2016