Fill out and attach this form to your application when operating more than four non-road engines at one location.

I. Company Information

1. Company Name:
2. Facility Location:

II. RESPONSIBLE OFFICIAL SIGNATURE BLOCK (The responsible official is the person responsible for overall operation of and ongoing compliance at the facility.)

I certify, based on information and belief formed after reasonable inquiry, the statements and information in this application are true, accurate, and complete.
Printed Name Title
Signature Date

III. Non-Road engine information

Engine #5
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line:______feet / Engine #6
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet
Engine #7
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet / Engine #8
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet
Engine #9
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet / Engine #10
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet
Engine #11
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet / Engine #12
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet
Engine #13
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet / Engine #14
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet
Engine #15
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet / Engine #16
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet
Engine #17
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet / Engine #18
Function or purpose: ______
Engine manufacturer: ______
Model: ______
Serial number: ______
Year of manufacture: ______
Fuel used: ______
Engine size: ______hp
Maximum hourly fuel: ______gal/hr
Height of exhaust stack: ______feet
Stack velocity: ______ft/sec
Operating stack temp.: ______°F
Stack area (inside diameter): ______inches²
Distance to property line: ______feet

ECY 070-406 Page 1 of 3

If you need this document in a format for the visually impaired, call the Air Quality Program at 360-407-6800. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.