NMED USE ONLY NMED USE ONLY reporting submittal form Staff TEMPO Admin PLEASE NOTE: ® - Indicates required field SECTION I - GENERAL COMPANY AND FACILITY INFORMATION A. ® Company Name: D. ® Facility Name: B.1 ® Company Address: E.1 ® Facility Address: B.2 ® City: B.3 ® State: B.4 ® Zip: E.2 ® City: E.3 ® State: E.4 ® Zip: C.1 ® Company Environmental Contact: C.2 ® Title: F.1 ® Facility Contact: F.2 ® Title: C.3 ® Phone Number: C.4 ® Fax Number: F.3 ® Phone Number: F.4 ® Fax Number: C.5 ® Email Address: F.5 ® Email Address: G. Responsible Official: (Title V only): H. Title: I. Phone Number: J. Fax Number: K. ® AI Number: L. Title V Permit Number: M. V Permit Issue Date: Permit Number: O. NSR Permit Issue Date: P. Reporting Period: From: To: SECTION II TYPE OF SUBMITTAL (check one that applies) – Permit Condition(s): Description: Title V Annual Compliance A. Certification Permit Condition(s): Description: Title V Semi-Annual B. Monitoring Report Regulation: Section(s): Description: NSPS Requirement C. (40CFR60) Regulation: Section(s): Description: MACT Requirement D. (40CFR63) Regulation: Section(s): Description: NMAC Requirement E. (20.2.xx) or NESHAP Requirement (40CFR61) Permit No.: or NOI No.: Condition(s): Description: Permit or Notice of Intent F. (NOI) Requirement NOV No. : or SFO No. : Section(s): Description: Requirement of an or CD No. : or : G. Enforcement Action SECTION III - CERTIFICATION After reasonable inquiry, I certify that the information in this submittal is true, accurate and complete. (name of reporting official) ® Signature of Reporting Official: ® Title: ® Date ® Responsible Official for Title V? Yes No
NMED USE ONLY NMED USE ONLY TEMPO reporting submittal form Staff Admin PLEASE NOTE: ® - Indicates required field SECTION I - GENERAL COMPANY AND FACILITY INFORMATION A. ® Company Name: D. ® Facility Name: B.1 ® Company Address: E.1 ® Facility Address: B.2 ® City: B.3 ® State: B.4 ® Zip: E.2 ® City: E.3 ® State: E.4 ® Zip: C.1 ® Company Environmental Contact: C.2 ® Title: F.1 ® Facility Contact: F.2 ® Title: C.3 ® Phone Number: C.4 ® Fax Number: F.3 ® Phone Number: F.4 ® Fax Number: C.5 ® Email Address: F.5 ® Email Address: G. Responsible Official: (Title V only): H. Title: I. Phone Number: J. Fax Number: K. ® AI Number: L. Title V Permit Number: M. V Permit Issue Date: Permit Number: O. NSR Permit Issue Date: P. Reporting Period: From: To: SECTION II – TYPE OF SUBMITTAL (check one that applies) A. Title V Annual Compliance Certification Permit Condition(s): Description: B. Title V Semi-Annual Monitoring Report Permit Condition(s): Description: C. NSPS Requirement (40CFR60) Regulation: Section(s): Description: D. MACT Requirement (40CFR63) Regulation: Section(s): Description: E. NMAC Requirement (20.2.xx) or NESHAP Requirement (40CFR61) Regulation: Section(s): Description: F. Permit or Notice of Intent (NOI) Requirement Permit No.: or NOI No.: Condition(s): Description: G. Requirement of an Enforcement Action NOV No. : or SFO No. : Section(s): Description: or CD No. : or : SECTION III - CERTIFICATION After reasonable inquiry, I certify that the information in this submittal is true, accurate and complete. (name of reporting official) ® Signature of Reporting Official: ® Title: ® Date ® Responsible Official for Title V? Yes No
Reporting-Submittal-Form-v0418.docx