Indiana Department of Environmental Management Permits Branch, Office of Air Quality 100 North Senate Avenue, P.O. Box 6015 Indianapolis, Indiana 46206-6015 (and local agency if applicable) State Form 51655 (3-04) Date:_______________________ Sub: Request for Permit Change in regard to changes in 326 IAC 2-6 (Emission Reporting) This application is a request to change the existing air permit or registration conditions (as the case may be) to incorporate the requirements per the recent changes in 326 IAC 2-6 (Emission Reporting) as adopted by the Air Pollution Control Board on December 3, 2003. Source Name: __________________________________________ Source Address: ________________________________________ City: _________________________ County: __________________________ ZIP Code: _____________ Mailing Address (if different): ________________________________________ City: _________________________ County: __________________________ ZIP Code: _____________ Name of Contact Person : ________________________________________ Electronic Mail Address (optional): ________________________________________ Telephone Number: ________________________________________ Facsimile Number (optional): ________________________________________ Name of Authorized Individual or Responsible Official: __________________________________ Identification Number of Permit to be changed: _ _ _ - _ _ _ _ _- _ _ _ _ _ Type of permit change requested: Notice Only Change Administrative Amendments Notice Only Change Administrative Permit Amendment Administrative Permit Amendment Permit Level and type of change approval requested: If you have: Registration Source Specific Operating Permit (SSOA) Minor Source Operating Permit (MSOP) Federally Enforceable State Operating Permit (FESOP) Part 70 Operating Permit (Title V Permit)
Please identify here the emission reporting requirement (or the absence of such) for source:
Certification of Truth, Accuracy, and Completeness In case of Registration, MSOP and FESOP, the authorized individual as defined in 326 IAC 2-1.1-1 (1) shall sign this certification. In case of SSOA and Title V Permit, the Responsible Official as defined in 326 IAC 2-7-1 (34) shall sign this certification. I certify under penalty of law that, based on information and belief formed after reasonable inquiry, the statements and information contained in this application are true, accurate, and complete. _________________________________________ Name and Designation (typed) ________________________________________ Signature _______________________________________ Title _____________________________________ Date