Title V Annual Compliance Certification Form and Instructions
What is a Title V Annual Compliance Certification?
Every holder of a Title V Air Operating Permit is required by 40 CFR 70.6(c)(5) to submit an
“Annual Compliance Certification” to the Administrator (US EPA Region 6) as well as to the
permitting authority (ADEQ). This requirement is repeated in every Arkansas Air Operating
Permit for Title V facilities as General Provision 21.
The Arkansas Department of Environmental Quality has developed, with assistance from US
EPA Region 6, forms and guidelines to aid facilities in fulfilling this obligation.
When is my Annual Compliance Certification due?
Unless the Department has agreed (in writing) to alternative dates, the Annual Compliance
Certification is due on or before the first business day of the second month after the
anniversary month of the permit. The reporting period covers a full year and ends on the last
day of the anniversary month of the permit. For example:
For a Permit issued any time during the month of May:
The Reporting period is:
June 1 through May 31
Reports are due:
July 1 of every year
Failure to submit the Compliance Certification to ADEQ by the due date may result in
Enforcement action. A list of Compliance Deadlines and coverage periods is found on the
ADEQ website.
How do I submit my Annual Compliance Certification?
The Annual Compliance Certification is submitted to ADEQ and also to US EPA Region 6. The
addresses are as follows:
Heinz Braun
Arkansas Department of Environmental Quality
Air Division – Compliance Monitoring Section
5301 NorthShore Drive
North Little Rock, AR 72118
David F. Garcia (6EN-A)
Associate Director
Air/Toxics & Inspection Coordination Branch
U.S. EPA, Region 6
1445 Ross Avenue
Dallas, TX 75202
Any report that is required to be sent to ADEQ Air Enforcement or Air Compliance Monitoring
may now be sent electronically to airsubmission@adeq.state.ar.us. Reports to EPA must still
be mailed.
Revised 9/12/2012
The submission should be CLEARLY identified as an “Annual Compliance Certification” or as a
“Semi-annual Monitoring Report,” and the facility name, AFIN, Permit # and a page number
should be on EVERY page of the submission. Many facilities have to attach additional pages
to Part 2 of the form. If you do so, it is essential that you add the identifying information to
the additional pages.
Is the Annual Compliance Certification the same thing as my Monitoring Report?
No. The Annual Compliance Certification is NOT the same as the Semi-Annual Monitoring
Report required in General Provision 7 of your permit. The Semi-Annual Monitoring Report is
submitted only to ADEQ. There are additional instructions and example files on this site that
deal with Semi-Annual Monitoring Reports.
The distinction is important, because most facilities have a Semi-Annual Monitoring Report
due at the same time as the Annual Compliance Certification. Although you can submit them
in the same mailing, separate certification sheets are required and the two reports should not
be stapled together.
What form do I use to submit the Annual Compliance Certification?
The Annual Compliance Certification form is attached to this document. Note that it consists
of 4 parts.
Part 1 is the Compliance Certification page. This Part must be signed in ink by a
“Responsible Party” at the facility. A secretary cannot sign in lieu of the person listed as the
“Responsible Party”. The person whose name is written or typed in must be the person who
signs the document and accepts the consequences of falsification.
Part 2 is the Compliance Certification Data. Every condition of the permit should be certified.
Note that if additional pages are attached to this Part, they should also have the facility name,
AFIN, Permit # and a page number at the top of each page. Column 9 of this Part expects a
“Y” to indicate that a facility was in complete compliance with the requirement, or a number
representing the number of times that the facility was out of compliance with the
requirement.
Part 3 is the Deviation and Excess Emission Certification page. This Part consists of two
questions, which are self-explanatory.
Part 4 is the Deviation and Upset Condition Summary Table, and is only required if there
have been Deviations or Upset Conditions during the reporting period.
Where is the form?
The form to be used in satisfying 40 CFR 70.6(c)(5) follows.
Revised 9/12/2012
Arkansas Air Operating Permit Annual Compliance Certification Form
(Part 1)
Identifying Information
AFIN: _____________ Permit Number: ______________ Permit Issued Date: ___________
Facility Name:__________________________________________________
Facility Address: ________________________________________________
City: ____________________________ State: ____________ Zip Code: _______________
Responsible Official: _______________________ Ph No.:__________ Fax No.: __________
Technical Contact: ________________________ Ph No.:__________ Fax No.: __________
Principal Product or Business: ______________________Primary NAICS Code: _________
Certification of Truth, Accuracy, and Completeness (By Responsible Official)
I,
certify that, based on information and belief formed
after reasonable inquiry, the statements and information contained in the attached annual
compliance certification are true, accurate, and complete.
Signature __________________________________________ Date: _________________
Responsible Official Title: _________________________________________
Page 1 of ___
Revised 9/12/2012
Arkansas Air Operating Permits Annual Compliance Certification Form
Facility Name:
AFIN: _
-
__
Permit: __ -AOP-R
(Part 2)
Period: _ _/ _ _ through __ / __ _.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Permit
Condition
Reference
Source
No.
Source Description
Pollutant
Monitoring
Method
(Rule Citation)
Permitted Emission
Limit or Operating
Condition
Actual Emissions or
Operating Conditions
Continuous
Compliance?
( Y or # )
Permit Condition Reference:
SC-Specific Condition, PC-Plantwide Condition, GP-General Provision
Rule Citation: Cite rule/regulation ( NSPS subpart, NESHAP subpart, etc... ) if provided in your permit condition.
Continuous Compliance?: Yes or (#) of individual deviations and upset conditions. See Part 3
Page ___ of
Revised 10/15/2008
Arkansas Air Operating Permit Annual Compliance Certification Form
Air Operating Permit Number: ________________________
AFIN: _____________
Company Name: __________________________________
Period: _______________ Through __________________
(Part 3)
Deviation and Excess Emission Reporting
Question
Response (Yes/No)
Are there any deviations or upset conditions being reported with this
annual compliance certification? If yes complete the table entitled
ADeviation and Upset Condition Summary Report@ (Part 4).
Have there been any previous deviation or upset condition reports
forwarded to ADEQ during this reporting period? If yes, attach a
copy of the report(s) and complete (Part 4).
Reporting of upset conditions is only required when the source exceeds the emission limit established by the permit, for longer than thirty (30) minutes, in the aggregate,
during a twenty-four hour period.
All deviations must be reported on the Annual Compliance Certification.
Page ___ of ___
Revised 10/15/2008
Arkansas Air Operating Permit Annual Compliance Certification Form
Deviation and Upset Condition Summary Report
Air Operating Permit Number: ________________________
AFIN: _____________
Company Name: __________________________________
Period: _______________ Through __________________
(Part 4)
Deviation and Upset Condition Report Summary
No.
Source
No.
Pollutant
Permit Number:
Applicable Requirement
(Include Rule Citation)
Monitor Method
(Include Rule Citation)
Monitoring
Frequency
Total # of
Dev and UC
ADev@ Deviation; AUC@ Upset Condition
Deviation and Upset Condition Report
No.
Dev or UC Started
Dev or UC Ended
Date
Date
Time
Time
# of Hours
Cause of Dev or UC
Corrective Action Taken
Revised 10/15/2008