Notification of Case-By-Case Insignificant Activity

Louisiana Administrative Code 33:III.501.B.5 - Table D

Date Submitted: ______

1. Name of Owner:

______

2. Name of Operator if Different than Owner:

______

3. Agency Interest No.: ______

4. Mailing Address of Applicant:

______

______

______

5. Location of Source:

City: / State:
Parish: / Latitude:
Zip Code: / Longitude:

6. Is the source subject to a Part 70 Operating Permit?

If yes, provide permit number. Part 70 Permit No.: ______

7. Is the source subject to a State Air Permit?

If yes, provide permit number. State Air 70 Permit No.: ______

8. Description of Insignificant Activity (including, annual amount of emissions, source of emissions, anticipated duration, etc.)

______

______

______

______

______

9. Please provide the name, title, phone number and email address of a contact person from whom the Department may request any additional information.

Name: ______

Title: ______

Phone No.: ______

Email: ______

10. In submitting this notification, the owner or operator certifies that the insignificant activity will satisfy the following criteria:

A. The emissions unit emits and has the potential to emit no more than five (5) tons per year of any regulated pollutant (attach calculations);

B. The emissions unit emits and has the potential to emit less than the minimum emission rate listed in Table 51.1, LAC 33:III.Chapter 51, for each Louisiana air toxic pollutant;

C. The emissions unit emits and has the potential to emit less than the de minimis rate established pursuant to section 112(g) of the federal Clean Air Act for each hazardous air pollutant; and

D. No enforceable permit conditions are necessary to ensure compliance with any applicable requirement.

11. Pursuant to LAC 33:III.501.B.5  Table D, the owner or operator agrees to attach this notification to its most recent Part 70 operating permit or state air permit. The owner or operator further agrees to include the activity as an insignificant activity in its permit at the next permit renewal or permit modification, as appropriate.

12. The owner or operator certifies that the activity will not cause a nuisance or a danger to public health or safety.

13. The owner or operator agrees to pay a permit fee (Permit Fee 2010) to the Louisiana Department of Environmental Quality within 30 days of submitting the notification.

14. Notification forms submitted in the past 12 months:

Date Submitted / Brief Description of Activity

Certification

I certify, based on information and belief, formed after a reasonable inquiry that the above information is true, accurate, and complete.

Name: ______

Date: ______

Title: ______

Signature: ______