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Operating Permit Application Forms & Emission Inventory/Fee Payment Forms


Below are operating permit application forms and instructions. They were developed using Microsoft Word. Please do not alter the forms in any way, such as changing the row and column dimensions or the text.

In order to view the PDF files you will need to install Adobe Acrobat Reader on your computer. If you cannot view the files, you can receive copies of the forms by sending your name and address to Chris Kjellmark, Air Quality Bureau, Department of Natural Resources, 7900 Hickman Road, Suite 1, Windsor Heights, IA 50324. Or reach him by phone at (515) 281-7826, or by email at chris.kjellmark@dnr.iowa.gov.


Other Inventory Forms Title V Emissions Inventory/Fee Payment Form Packages

These forms are only required for facilities that have applied for a Title V operating permit. Instructions for completing each form is located in the Title V application instructions below.


Title V/Voluntary Operating Permit (VOP) Form Packages
Operating Permit by Rule for Small Sources (50%) Form Packages
  • Complete set of Small Source application forms (PDF Zip File)
  • Small Source application instructions (PDF File)

Individual Title V and VOP Forms

Form Form # File Type
Part 1:
Form 1.0 - Facility Identification542-4006 PDF File DOC File
Form 1.2 - Schematic - Process Flow Diagram 542-1475 PDF File DOC File
Form 1.3 - Insignificant Activities - Potential Emissions 542-1477 PDF File DOC File
Form 1.4 - Potential Toxic Emissions - Significant Activities 542-4011 PDF File DOC File
Form 1.5 - Potential Emissions - Significant Activities 542-4012 PDF File DOC File
Form 2.0 - Emission Point Information 542-4013 PDF File DOC File
Form 3.0 - Emission Unit Description - Potential Emissions 542-4014 PDF File DOC File
Form 4.0 - Emissions Unit - Actual Operations & Emissions 542-4007 PDF File DOC File
Form 5.0 - Title V Annual Emissions Summary/Fee 542-4008 PDF File DOC File
Form CA-01 - Calculations 542-4010 PDF File DOC File
Form CE-01 - Pollution Control Equipment Data Sheet 542-4015 PDF File DOC File
Form ME-01 - Continuous Monitoring Systems 542-1484 PDF File DOC File

Part 2:
Section 1
Form RE-00 Requirements Review 542-1487 PDF File DOC File
Form RE-01 NESHAP - National Emission Standards for Hazardous Air Pollutants for Source Categories (40 CFR 63) & Prevention of Accidental Release 542-1488 PDF File DOC File
Form RE-02 NESHAP - National Emissions Standards for Hazardous Air Pollutants (40 CFR 61) 542-1489 PDF File DOC File
Form RE-03 PSD - Prevention of Significant Deterioration 542-1490 PDF File DOC File
Form RE-04 NSPS - New Source Performance Standards 542-1491 PDF File DOC File
Form RE-05 Acid Rain, CAIR, and CAMR 542-1492 PDF File DOC File
Form RE-06 Stratospheric Ozone Requirements 542-1493 PDF File DOC File
Form RE-07 State Rules 542-1494 PDF File DOC File
Form RE-08 CAM - Compliance Assurance Monitoring 542-4016 PDF File DOC File
Section 2
Form AR-00 Applicable Requirements 542-1495 PDF File DOC File
Form AR-01 Applicable Requirements & Compliance Plan - by Emission Unit 542-1496 PDF File DOC File
Form AR-02 Applicable Requirements & Compliance Plan - by Applicable Requirement 542-1497 PDF File DOC File
Section 3
Form CP-00 Compliance Plan, Schedule & Certification 542-1498 PDF File DOC File
Form CP-01 Compliance Plan, Schedule & Certification - by Emission Unit 542-1499 PDF File DOC File
Form CP-02 Compliance Plan, Schedule & Certification - by Applicable Requirement 542-1500 PDF File DOC File
Section 4
Form PR-00 Proposals (Limits & Alternatives) 542-1501 PDF File DOC File
Form PR-01 Proposed Limits 542-1502 PDF File DOC File
Form PR-02 Alternative Operating Scenario 542-1503 PDF File DOC File
Form PR-03 Early Reduction 542-1504 PDF File DOC File

Part 3:

Application Certification 542-1486 PDF File DOC File


Individual Small Source (50%) Forms

Form 1.0 - Facility Identification - Certification 542-1520 PDF File
Form EU.1 - Emission unit Description 542-1521 PDF File
Form PCE.1 - Pollution Control Equipment Data Sheet 542-1522 PDF File
Form HAP.1 - Actual Emissions - Hazardous Air Pollutant Data Sheet 542-1523 PDF File


CAIR Application Form (Chris Kjellmark: 281-7826)

CAIR Permit Application DOC File
EPA Website Containing CAMD Certificate of Representation Form





 

Free Adobe Acrobat Download

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