General Permit for Gasoline Facility Non-Major Sources

Navajo Nation Environmental Protection Agency

Air Quality Control Program - Minor Source Program

REQUEST FOR COVERAGE UNDER THE GENERAL PERMIT FOR GASOLINE DISPENSING FACILITY NON-MAJOR SOURCES AND MINOR MODIFICATIONS TO NON-MAJOR SOURCES

1) Purpose of Application (check one):*

Application for an Existing True, Non-Major Gasoline Dispensing FacilityApplication to Construct a New True, Non-Major Gasoline Dispensing FacilityApplication to Construct a Minor Modification to an Existing True, Non-Major Gasoline Dispensing Facility

2) Name of Gasoline Dispensing Facility*

Name

Street Address of Gasoline Dispensing Facility (or description of location including GPS coordinates). Provide latitude and longitude location(s) in decimal degrees, indicating the datum used in parentheses. These are GPS (global positioning system) coordinates. This information should be provided in decimal degrees with 6 digits to the right of the decimal point, indicating the datum used in parentheses (i.e., NAD 27, NAD 83, WGS 84 – WGS 84 is preferred over NAD 27).*

City*

State*

Zip Code*

3) Name of Gasoline Dispensing Facility Owner - List the complete company name and/or the full name (last, middle initial, first) of all owners of the source. For corporations, include divisions or subsidiary name, if any. *

Name

Street Address of Gasoline Dispensing Facility Owner*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Telephone*

4) Name of Gasoline Dispensing Facility Operator*

Name

Mailing Address of Gasoline Dispensing Facility Operator*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Telephone*

5) Authorized Contact regarding Permitting and Environmental Matters (if Owner or Operator, write "Owner" or "Operator") - The authorized contact is the person in charge of the source’s compliance with the Minor Source Program Regulations and this general permit. *

Name

Title*

Street Address or P.O. Box*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Telephone*

6) For existing GDF sources, date of construction

Date

7) a. For new GDF sources, description of source

b. For new GDF sources, date construction is scheduled to begin

Date

8) a. For minor modifications to an existing GDF source, description of modification

b. For minor modifications to an existing GDF source, date construction is scheduled to begin

Date

9) a. North American Industry Classification System*

The NAICS Code for your gasoline dispensing facility can be found at the following link for North American Industry Classification System: https://www.census.gov/naics/.

b. Standard Industrial Classification Code*

Although the new NAICS code has replaced the SIC codes, much of the Clean Air Act permitting processes continue to use these codes. The SIC Code for your gasoline dispensing facility can be found at the following link for Standard Industrial Classification Codes: http://www.osha.gov/pls/imis/sic_manual.html.

10) Name of Tank Truck Company(ies) Supplying Fuel to the Gasoline Dispensing Facility*

11) Information regarding Underground and Above Ground Storage Tanks at Gasoline Dispensing Facility (including diesel tanks). Click "Add Tank" to list multiple storage tanks.

12) I have conducted an initial performance test for every dual-point vapor balance system covered by this permit and the vapor balance system is operable.*

YesNo

13) Information regarding Emergency Engines at Gasoline Dispensing Facility

	Unit or Serial ID #	Type of Fuel	Subject to V.G.3, 4, or 5 (include model year and manufacture date)?	Existing, New or Modified (include installation date for existing)	Horsepower
1
2
3
4
5

14) Other Information Demonstrating Coverage under this General Permit

15) Compliance Status: a. Is the source currently operating in compliance with any applicable regulations or any existing permit?*

YesNo

i. If no, identify and describe the noncompliance.

b. Has the source’s compliance with any applicable regulations or existing permits been continuous or intermittent?*

ContinuousIntermittent

i. If intermittent, identify and describe each deviation.

c. Is the source currently subject to a compliance plan?*

Yes (include the compliance plan as an attachment)No

Attach Compliance Plan

16) Attach Emissions Units Documentation

For each emissions unit, include supporting documentation for the PTE of each unit with your Request for Coverage. For new units, include estimated emissions. In addition, for existing emission units, include the most recent actual annual emissions. (For more information on how to calculate actual emissions, go to: https://www.epa.gov/tribal-air/registration-existing-true-minor-sources-air-pollution-indian country). As needed, please include any other relevant information with your Request for Coverage.

Applicant's Statement (to be signed by the Applicant)

I certify to the truth, accuracy, and completeness of all statements and any supplementary information submitted with this application. I affirm that the Gasoline Dispensing Facility(ies) for which I am requesting coverage under the Gasoline Dispensing Facility General Permit will comply with all applicable laws and regulations.

Name*

Title*

Company*

Date*

Date

Signature*

Information in these forms submitted to seek coverage under this general permit in compliance with the MSPR may be claimed as confidential. A company may assert a claim of confidentiality for information submitted by clearly marking that information as confidential. Such information shall be treated in accordance with the Navajo Nation Privacy and Access to Information Act codified in Title 2, Chapter 2 of the Navajo Nation Code, and will only be disclosed by the means set forth in that statute. Information collected pursuant to NNCAA § 1151(A), (B), and (C) shall be available to the public as provided in NNCAA § 1151(D), except upon a showing satisfactory to the Director by any person that records, reports or information, or any portion thereof (other than emission data), would, if made public, divulge methods or processes entitled to protection as trade secrets.