Title V Annual Compliance Certification Form and Instructions

What is a Title V Annual Compliance Certification?

Every holder of a Title V Air Operating Permit is required by 40 CFR 70.6(c)(5) to submit an “Annual Compliance Certification” to the Administrator (US EPA Region 6) as well as to the permitting authority (ADEQ). This requirement is repeated in every Arkansas Air Operating Permit for Title V facilities as General Provision 21.

The Arkansas Department of Environmental Quality has developed, with assistance from US EPA Region 6, forms and guidelines to aid facilities in fulfilling this obligation.

When is my Annual Compliance Certification due?

Unless the Department has agreed (in writing) to alternative dates, the Annual Compliance Certification is due on or before the first business day of the second month after the anniversary month of the permit. The reporting period covers a full year and ends on the last day of the anniversary month of the permit. For example:

For a Permit issued any time during the month of May:

The Reporting period is: June 1 through May 31

Reports are due: July 1 of every year

Failure to submit the Compliance Certification to ADEQ by the due date may result in Enforcement action. A list of Compliance Deadlines and coverage periods is found on the ADEQ website.

How do I submit my Annual Compliance Certification?

The Annual Compliance Certification is submitted to ADEQ and also to US EPA Region 6. The addresses are as follows:

Heinz Braun

Arkansas Department of Environmental Quality

Air Division – Compliance Monitoring Section

5301 NorthShore Drive

North Little Rock, AR 72118

David F. Garcia (6EN-A)
Associate Director
Air/Toxics & Inspection Coordination Branch
U.S. EPA, Region 6
1445 Ross Avenue
Dallas, TX 75202

Any report that is required to be sent to ADEQ Air Enforcement or Air Compliance Monitoring may now be sent electronically to . Reports to EPA must still be mailed.

The submission should be CLEARLY identified as an “Annual Compliance Certification” or as a “Semi-annual Monitoring Report,” and the facility name, AFIN, Permit # and a page number should be on EVERY page of the submission. Many facilities have to attach additional pages to Part 2 of the form. If you do so, it is essential that you add the identifying information to the additional pages.

Is the Annual Compliance Certification the same thing as my Monitoring Report?

No. The Annual Compliance Certification is NOT the same as the Semi-Annual Monitoring Report required in General Provision 7 of your permit. The Semi-Annual Monitoring Report is submitted only to ADEQ. There are additional instructions and example files on this site that deal with Semi-Annual Monitoring Reports.

The distinction is important, because most facilities have a Semi-Annual Monitoring Report due at the same time as the Annual Compliance Certification. Although you can submit them in the same mailing, separate certification sheets are required and the two reports should not be stapled together.

What form do I use to submit the Annual Compliance Certification?

The Annual Compliance Certification form is attached to this document. Note that it consists of 4 parts.

Part 1 is the Compliance Certification page. This Part must be signed in ink by a “Responsible Party” at the facility. A secretary cannot sign in lieu of the person listed as the “Responsible Party”. The person whose name is written or typed in must be the person who signs the document and accepts the consequences of falsification.

Part 2 is the Compliance Certification Data. Every condition of the permit should be certified. Note that if additional pages are attached to this Part, they should also have the facility name, AFIN, Permit # and a page number at the top of each page. Column 9 of this Part expects a “Y” to indicate that a facility was in complete compliance with the requirement, or a number representing the number of times that the facility was out of compliance with the requirement.

Part 3 is the Deviation and Excess Emission Certification page. This Part consists of two questions, which are self-explanatory.

Part 4 is the Deviation and Upset Condition Summary Table, and is only required if there have been Deviations or Upset Conditions during the reporting period.

Where is the form?

The form to be used in satisfying 40 CFR 70.6(c)(5) follows.


Arkansas Air Operating Permit Annual Compliance Certification Form

(Part 1)

Identifying Information
AFIN: ______Permit Number: ______Permit Issued Date: ______
Facility Name:______
Facility Address: ______
City: ______State: ______Zip Code: ______
Responsible Official: ______Ph No.:______Fax No.: ______
Technical Contact: ______Ph No.:______Fax No.: ______
Principal Product or Business: ______Primary NAICS Code: ______
Certification of Truth, Accuracy, and Completeness (By Responsible Official)
I, certify that, based on information and belief formed after reasonable inquiry, the statements and information contained in the attached annual compliance certification are true, accurate, and complete.
Signature ______Date: ______
Responsible Official Title: ______

Page 1 of ___

Revised 9/12/2012

Arkansas Air Operating Permits Annual Compliance Certification Form (Part 2)

Facility Name: AFIN: _ - __ Permit: __ -AOP-R Period: _ _/ _ _ through __ / __ _.

(1)
Permit
Condition
Reference / (2)
Source No. / (3)
Source Description / (4)
Pollutant / (5)
Monitoring
Method
(Rule Citation) / (6)
Permitted Emission
Limit or Operating Condition / (7)
Actual Emissions or
Operating Conditions / (8)
Continuous Compliance?
( Y or # )

Permit Condition Reference: SC-Specific Condition, PC-Plantwide Condition, GP-General Provision

Rule Citation: Cite rule/regulation ( NSPS subpart, NESHAP subpart, etc... ) if provided in your permit condition.

Continuous Compliance?: Yes or (#) of individual deviations and upset conditions. See Part 3 Page ___ of


Arkansas Air Operating Permit Annual Compliance Certification Form

Air Operating Permit Number: ______AFIN: ______

Company Name: ______

Period: ______Through ______

(Part 3)

Deviation and Excess Emission Reporting
Question / Response (Yes/No)
Are there any deviations or upset conditions being reported with this annual compliance certification? If yes complete the table entitled ADeviation and Upset Condition Summary Report@ (Part 4).
Have there been any previous deviation or upset condition reports forwarded to ADEQ during this reporting period? If yes, attach a copy of the report(s) and complete (Part 4).

Reporting of upset conditions is only required when the source exceeds the emission limit established by the permit, for longer than thirty (30) minutes, in the aggregate, during a twenty-four hour period.

All deviations must be reported on the Annual Compliance Certification.

Page ___ of ___


Arkansas Air Operating Permit Annual Compliance Certification Form

Deviation and Upset Condition Summary Report

Air Operating Permit Number: ______AFIN: ______

Company Name: ______

Period: ______Through ______

(Part 4)

Deviation and Upset Condition Report Summary Permit Number:
No. / Source No. / Pollutant / Applicable Requirement
(Include Rule Citation) / Monitor Method
(Include Rule Citation) / Monitoring Frequency / Total # of Dev and UC

ADev@ Deviation; AUC@ Upset Condition

Deviation and Upset Condition Report
No. / Dev or UC Started / Dev or UC Ended
Date / Time / Date / Time / # of Hours / Cause of Dev or UC / Corrective Action Taken

Revised 10/15/2008