CONSTRUCTION/OPERATION CHANGE
NOTIFICATION
(This notification form is emission source specific and shall be used for each emission source modification or construction)
Facility Name:
Site Address:
Permit to Construct/Operate No.:
Modification #
Date:
A) Description of Physical or Operational Change of Emission Source:
B) Anticipated Date of Construction/Modification of Emission Source:
C) Emission Source Information:
Equipment/Operation
Change
(give complete description,
ie. mfg, model#, belt width, screen
configuration & size, rated capacities, etc.)
Source
ID#
Equipment
Date of
Construction
Is this a
Like-for-Like
Replacement?
Subject
to
NSPS?
Pollutant
Emission Rates*
Actual
(lbs/hr)
Actual
(lbs/yr)
Potential
(lbs/hr)
Potential
(lbs/yr)
PM-10
VOC
NOx
SO2
CO
TAP
HAP
*All emission rate calculations shall be based on sound engineering principles and must be provided with this notification as supporting documentation. Show source for
emission factors (ie. AP-42, stack testing, etc)
D) Regulatory Review: Provide citation of applicable MCAPCO regulation(s) and detail any and all emission standards associated with the proposed
change referenced in Part A of this Notification:
APPLICABLE REGULATION(s)
EMISSION STANDARD(s)
E) Monitoring and Reporting: Provide proposed monitoring and reporting conditions for the physical and/or operational change referenced in Part A of
this Notification.
MONITORING
REPORTING
Note: Sources subject to NSPS - Subpart OOO may have reporting requirements per 40 CFR 60.676.
F) Facility-wide Emissions Summary:
Pollutant
Facility-Wide Potential Emissions (tons/year)
Baseline
Potential
Emissions
Proposed
Modification
Previous
Modifications
in Calendar
Year
Facility-wide
Potential
(A)
(B)
(C)
(A+B+C)
VOC
PM-10
NOx
SO2
CO
HAPs
TAPs
Refer to General Condition and Limitation No. G-20 and Appendix A
G) Certification Statement:
I hereby certify that I have reviewed the information contained in this Construction/Operational Change Notification and that, to
the best of my knowledge and belief, the submitted information is true, accurate, and complete (G.S. §143-512.3(a)(2)). Further,
I shall assume all responsibility for any construction and operational changes as described herein and certify that these changes
are not in violation of any MCAPCO regulation or any conditions listed in the facility’s valid Permit to Construct/Operate.
Additions of and/or changes to any equipment or processes as described within this notification will not take place until 15 days
after this notice is submitted and written approval is supplied by MCAQ, pursuant to the permit.
_____________________________________________________________
Print Name and Official Title of Owner/Operator or Responsible Management Official
________________________________________________________
Authorized Signature
Date
FOR MCAQ USE ONLY
Modification #______________________________
Reviewed By: ______________________________
Date: _______________