Semi-Annual Reporting Form for Boilers Under NSPS Subpart Dc
This form is used to report fuel consumption for boilers using distillate oil or distillate oil in
combination with natural gas. Please write legibly.
1. Name of facility
2. Air Permit number (PC/O#)
3. Address of facility
4. Name/Title of person filling out this form
5. Telephone Number
6. Calendar year of reporting period
7.
Reporting period:
(January 1 thru June 30 or July 1 thru December 31)
8.
Did you burn distillate oil this period?
(If no, please skip items 9, 10, and 11)
9.
Name of distillate oil supplier(s) for oil burned
this period
Fuel Oil Supplier Certification: For any oil burned this period, please supply a certification from the
10. oil supplier (attach a signed copy of this certification for more than one shipment per period):
Please sign the following statement regarding fuel usage: "The fuel supplier certification(s) submitted
represents all of the fuel (other than natural gas) combusted during the period"
11.
_______________________________________________
(Signature of responsible person or company official)
_______________
(date)
_______________________________________________
_______________
Return the completed form to:
Mecklenburg County Air Quality
2145 Suttle Avenue
Charlotte, NC 28208-5237
(704) 336-5430
Fax (704) 336-4391
MCAQ Semi-Annual NSPS Dc Reporting Form
Rev. 12/2015