AIR EMISSION CHECKLIST
Boilers and Furnaces
1) Submitted By
Name:
Date:
Title:
Phone: (_____)___________
2) Facility Name and Project #: ______________________________________________
Address: _____________________________________________________________
3) Boiler Number:
4) Type: _________________ Steam / Hot Water / Other:
5) Manufacturer:
Model Number:
6) Installation Date:
[Removal Date:
See Question 19)]
7) Start of Construction Date: ___________
8) Rated Heat Input:
9) Fuel Type
Btu/hr when burning: ______________________
Heat Value
%Sulfur
1.
Btu/ton / Btu/gal / Btu/cf
2.
Btu/ton / Btu/gal / Btu/cf
3.
Btu/ton / Btu/gal / Btu/cf
%Ash
10) Continuous Monitors: None / Steam Flow / Flue Gas Temperature / Opacity / SOx / NOx
11) Combustion Index, Diluent: None / O2 / CO
12) Rated Boiler Flue Gas Flow: acfm @ _______________ degrees F
13) Electrical Generation: No / Unit Number:
14) Pollution Control Equipment: No
Rated Electrical Output: ___MW
/
15) Stack/Exhaust Exit Data
Stack/Exhaust Exit No
Height:
feet above grade
Inside Dimension(s):
feet diameter or
Exhaust Gas Flow:
acfm @
feet x
feet
degrees F
16) Type of metering available (hourly run clock or fuel) that will allow ongoing reporting of operation to
MPCA.
17) If the unit is already in service, fuel consumption for each of the last two years based on operating hours
and rated heat input, a fuel monitoring gauge or utility bills.
Appendix HH – Part 2 – Air Emission Checklist
University of Minnesota, Facilities Management
March 2006
Page 1 of 2
Additional Information Requested
18) Site plan that indicates the relative position of the boiler/furnace stack on the building, as well as any
nearby offsite buildings, property lines or fences. All buildings and stack heights also need to be indicated.
19) Are any units being replaced or removed as part of this project? If yes, please complete a second form,
which indicates the planned removal date in question 6 as well as all other information.
Notes
Item 10 - Are there any continuous monitors to measure steam flow, flue gas temperature, opacity or
pollutants? If no, leave blank.
Item 11 - Are there are any combustion diluents?
Item 12 - What is the rated boiler flue gas flow in actual cubic feet per minute at degrees F
Item 14 - Determine whether or not the boiler has pollution control equipment (such as a low NOx burner)
Item 15 - Exhaust gas flow in acfm at the designated temperature in degrees F. Stack/exhaust exit number
refers to any established code by which the stack is referred to on plans or specifications. If none, leave
blank.
Please Return To:
Environmental Compliance Specialist
Department of Environmental Health and Safety
W-140 Boynton Health Service
University of Minnesota
410 Church Street SE
Minneapolis, MN 55455
Phone: (612) 626-7095
Fax: (612) 624-1949
End of Appendix HH - Part 2 - New Processes and Equipment that may Require Air
Permits
University of Minnesota Facilities Management and
Department of Environmental Health & Safety
March 2006
Appendix HH – Part 2 – Air Emission Checklist
University of Minnesota, Facilities Management
March 2006
Page 2 of 2