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 NON-MAJOR SOURCES AND MINOR MODIFICATIONS TO NON-MAJOR SOURCES IN THE OIL AND NATURAL GAS PRODUCTION AND NATURAL GAS PROCESSING SEGMENTS OF THE OIL AND NATURAL GAS SECTOR

1) Purpose of Application (check one):*

Application for an Existing True, Non-Major Oil and Natural Gas SourceApplication to Construct a New True, Non-Major Oil and Natural Gas SourceApplication to Construct a Minor Modification to an Existing True, Non-Major Oil and Natural Gas Source

2) Name of Oil and Natural Gas Source - Please note that a source is a site, place, or location that may contain one or more air pollution emitting units.*

Name

Street Address of Oil and Natural Gas Source (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 Oil and Natural Gas Source 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 Oil and Natural Gas Source Owner*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Telephone*

4) Name of Oil and Natural Gas Source Operator*

Name

Street Address of Oil and Natural Gas Source Operator*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Telephone*

5) Name and Address of Compliance Contact to whom Permitting and Environmental Correspondence is to be sent (if Owner or Operator, write "Owner" or "Operator"). The compliance contact is the person in charge of the source’s compliance with the Minor Source Program Regulations and this general permit. If this person is the same as the owner or the operator, please note this on the form. *

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) Type of Oil and Natural Gas Operation - Indicate the generally accepted name for the oil and natural gas production or natural gas processing segment operation (e.g., oil and gas well site, tank battery, compressor station, natural gas processing plant).*

a. NAICS Code*

The NAICS Code for your oil and natural gas source can be found at the following link for North American Industry Classification System: https://www.census.gov/naics/.

b. SIC 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 oil and natural gas source can be found at the following link for Standard Industrial Classification Codes: http://www.osha.gov/pls/imis/sic_manual.html.

c. Well ID Number(s) or API number(s), if applicable

Unique well identifier as assigned by the Federal or Tribal oil and gas regulatory agency, using the American Petroleum Institute (API) Standard for number format (pre-2014) or the Professional Petroleum Data Management (PPDM) Association U.S. Well Number Standard (2014-present). Provide IDs for all oil and natural gas production wells associated with the facility, if applicable. May not be applicable for downstream production sources, such as compressor stations.

7) Date Construction is Scheduled to Begin for a New Oil and Natural Gas Source:

Date

8) Date Construction is Scheduled to Begin for a Minor Modification to an Existing Non-Major Source, and Description of Modification:

9) Emissions and Other Source Information File Upload*

Include all of the following information in the table below and as attachments to this form uploaded to the box above. The information provided in attachments to respond to these requests will enable the Director to understand the type of oil and natural gas source seeking coverage and the nature and extent of the air pollutants to be emitted.

Note: The emission estimates can be based upon actual test data or, in the absence of such data, upon procedures acceptable to the Director and authorized by USEPA for such use. The following procedures are generally acceptable for estimating emissions from air pollution sources: (1) unit-specific emission tests; (2) mass balance calculations; (3) published, verifiable emission factors that are applicable to the unit (i.e., manufacturer specifications); (4) other engineering calculations; or (5) other procedures to estimate emissions specifically approved by the Director. Guidance for estimating emissions can be found at https://www.epa.gov/chief.

Narrative description of the operations.
Identification and description of any air pollution control equipment and compliance monitoring devices or activities.
Type and actual amount (annually) of each fuel that will be used.
Type of raw materials used (e.g., water for hydraulic fracturing).
Actual, annual production rates.
Actual operating schedules.
Any existing limitations on source operations affecting emissions or any work practice standards, where applicable, for all regulated air pollutants at your source. Indicate all requirements referenced in the MSPR that apply to emissions units and air pollution generating activities at the source. Include statements indicating each emissions unit that is an emissions unit potentially subject to the requirements referenced in the MSPR, but does not meet the definition of an affected facility under the referenced requirement, and therefore, is not subject to those requirements.
For each emissions unit comprising the source or modification, estimates of the total allowable (potential to emit) annual emissions at startup of production from the air pollution source for the following air pollutants: particulate matter, PM10, PM2.5, sulfur oxides (SOx), nitrogen oxides (NOx), carbon monoxide (CO), volatile organic compound (VOC), lead (Pb) and lead compounds, fluorides (gaseous and particulate), sulfuric acid mist (H2SO4), hydrogen sulfide (H2S), total reduced sulfur (TRS) and reduced sulfur compounds, including all calculations for the estimates. Allowable annual emissions are defined as: emissions rate of an emissions unit calculated using the maximum capacity of a stationary source to emit a pollutant under its physical and operational design. Any physical or operational limitation on the capacity of the source to emit a pollutant, including air pollution control equipment and restrictions on hours of operation or on the type or amount of material combusted, stored, or processed, shall be treated as part of its design if the limitation, or the effect it would have on emissions, is legally and practically enforceable. For new sources you must determine the potential for emissions within 30 days after the startup of production.
For each emissions unit comprising the source or modification, estimates of the total actual annual emissions during the upcoming, consecutive 12 months from the air pollution source for the following air pollutants: particulate matter (PM, PM10, PM2.5), sulfur oxides (SOx), nitrogen oxides (NOx), carbon monoxide (CO), volatile organic compound (VOC), lead (Pb) and lead compounds, ammonia (NH3), fluorides (gaseous and particulate), sulfuric acid mist (H2SO4), hydrogen sulfide (H2S), total reduced sulfur (TRS) and reduced sulfur compounds, including all calculations for the estimates. Estimates of actual emissions must take into account equipment, operating conditions, and air pollution control measures. You should calculate an estimate of the actual annual emissions using estimated operating hours, production rates, in-place control equipment, and types of materials processed, stored, or combusted.

10) Table of Emissions - Provide in the table below actual figures or estimates, depending on whether this form is submitted for existing or new/modified sources, of the total allowable annual emissions in tons per year (tpy) and total actual annual emissions (tpy) for the following pollutants for all emissions units comprising the source or modification. *

	TOTAL ALLOWABLE ANNUAL EMISSIONS (TPY)	TOTAL ACTUAL ANNUAL EMISSIONS (TPY)
PM
PM10
PM2.5
SOx
NOx
CO
VOC
Pb
NH3
Fluorides
H2SO4
H2S
TRS

11) Compliance Status: a. Is the source currently operating in compliance with any applicable regulations and 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

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 Oil and Natural Gas Source(s) for which I am requesting coverage under the Oil and Natural Gas Source 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.