EPA-450/4-88-008
Compilation of Air Toxics  Emission
      Inventory Questionnaires
                      By
                Engineering-Science, Inc.
               Gary, North Carolina 27513
                Contract No. 68-02-4398
            EPA Project Officer: James H. Southerfand

                    June 1988

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This report has been reviewed by the Office Of Air Quality Planning And Standards, U.S. Environmental
Protection Agency, and approved for publication as received from the contractor. Approval does not signify
that the contents necessarily reflect the views and policies of the agency, neither does mention of trade
names or commercial products constitute endorsement or recommendation for use.
                                      EPA-450/4-38-008

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                              LIST OF TABLES





Table



2-1  Potential  Demands upon Air Toxics Emission Inventories     5



2-2  Inventory Complexity as a Function of Application          6

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TABLE OF CONTENTS
 Chapter

 TITLE PAGE

 DISCLAIMER

 LIST OF  TABLES

 TABLE OF  CONTENTS

 EXECUTIVE SUMMARY

 CHAPTER  1:   INTRODUCTION
             1.1  Background
             1.2  Technical Approach

 CHAPTER  2:   CONSIDERATIONS FOR'DEVELOPING  QUESTIONNAIRES
             2.1  Screening Studies
             2.2  Sources To Be  Included
                 2.2.1  Criteria Pollutant  Data Base
                 2.2.2  Prioritized Substances
                 2.2.3  Selected SIC/SCC Codes
                 2.2.4  SARA 313 Toxics Release Inventory
                        Reporting .Form
                 2.2.5  Use of Permit Programs-For Air Toxics
                        Updates

 CHAPTER 3:  AIR TOXICS EMISSION INVENTORY QUESTIONNAIRE ELEMENTS
            3.1  Cover Letter
            3.2  Questionnaire Instructions
            3.3  Questionnaire Design
                 3.3.1   Open Ended Approach
                 3.3.2   Closed-Ended Approach
                 3.3.3   Emissions-Based Approach
                 3.3.4   Chemical-Use Approach
                 3.3.5   General Approach
                 3.3.6   Industry Specific Approach
                 3.3.7   Tiered Approach

CHAPTER  4:  OTHER CONSIDERATIONS
            4.1   The Right Questions
            4.2   The Return Rate
                 4.2.1  Minimize Questionnaire Length
                 4.2.2  Maximizing  Return Rates
            4.3   Confidentiality
            4.4   Applicability  and  Clarity  of Questions
            4.5   Complexity and Questionnaire Format
            4.6   Clarity  of Instructions
            4.7   Final Considerations
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Chapter

Chapter 5:
CHAPTER 6:
REFERENCES

APPENDICES

APPENDIX A

APPENDIX B

APPENDIX C

APPENDIX D


APPENDIX E

APPENDIX F

APPENDIX G
FOLLOW-UP PROCEDURES
5.1  Quality Control of Data
5.2  On-Site Inspections
5.3  Recontacting Sources
5.4  Revising the Questionnaire
VARIOUS STATE PROGRAMS
6.1  California
     Maryland
     Minnesota
     New York
     North Carolina ,
     Pennsylvania
     Rhode Island
            6.2
            6.3
            6.4
            6.5
            6.6
            6.7
EXAMPLE COVER LETTERS

EXAMPLE INSTRUCTION SHEETS      •

EXAMPLE CLOSED QUESTIONNAIRES

EXAMPLE CHEMICAL USE .VS. EMISSIONS BASED
QUESTIONNAIRES

EXAMPLE PERMIT TYPE QUESTIONNAIRES

EXAMPLE GENERAL QUESTIONNAIRE

EXAMPLE INDUSTRY SPECIFIC QUESTIONNAIRES

Example 1 Questionnaires

  o  Storage Tanks
  o  Dry Cleani ng
  o  Use of Waste Oils, Recycled Oils and/or'
     Sol vents for Fuel
  o  Degreasing, Cleaning and Surface Preparation
  o  Pesticide Use
  o  Surface Coating Operations
  o  Toxics in Processing and Manufacturing Operations
  o  Processing and Manufacturing Operations
     Using Volatile Organic Compounds
 22
 22
 22
 23
 23

 25
 25
 26
 26
 26
 26
 26
 27

 28

 29

A-l

B-l

C-l

0-1


E-l

F-l

G-l
                                   -  v

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Chapter                                                           Pagi

APPENDIX G (continued)

            Example 2

              o  Asbestos Products
              o  Tape Coating
              o  Electroplating
              o  Lead Battery Manufacturing
              o  Cooling Tower
              o  Semiconductor Manufacturing-
              o  Surface Coating
              o  Ethylene Oxide Sterilization

            Example 3

              o  Boiler Operation
              o  Incinerator Operation
              o  Asphalt Operation
              o  Grain Elevator
              o  Grain Mil 1
              o  Petroleum Product Storage  Tanks
              o  Petroleum Product Transfer Stations

APPENDIX H  EXAMPLE PRELIMINARY AND FOLLOW-UP  QUESTIONNAIRES       H-l

APPENDIX I  TOXIC CHEMICAL RELEASE INVENTORY REPORTING FORM        1-1

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                            EXECUTIVE SUMMARY
     Questionnaires have become an important tool in preparing air toxics
emission inventories.  This compilation process may simply involve the
development of a preliminary screening inventory, or may involve the
development of a detailed and comprehensive inventory.  The main question
to be addressed prior to developing a questionnaire is how the data
collected will be used.

     This report is intended as a resource for agencies interested in
developing air toxics emission inventory mail-out questionnaires.  The
questionnaires presented represent various formats dependent on the planned
use of the data and the agency's air toxics program.  Readers should not
assume that the questionnaires presented are the only appropriate formats
for air toxics emission inventory questionnaires, but they may want to
select certain features of these questionnaires to help meet particular
data gathering needs.

     The questionnaire designer must consider a wide range of options
that will maximize the efficiency of the questionnaire, the return rate,
and the accuracy of the resultant data collected.  In order to provide
quidance for formulating Questionnaires, representative types of ques-
tionnaires presently being used by State and local air pollution control
agencies are summarized and discussed in this report.  It  is intended to
be used as a guide for. agencies that plan to implement.or  expand their
air toxics program and/or air toxics emission inventory.   It is not intended
to be a stand alone guide to air toxics program development or as a- develop-
ment guide for computerized data handling systems.  It should be considered
one of several air toxics resources of information that when used together
present clearer overall program development considerations.

     The introduction relates the need for and use of questionnaires in
an air toxics framework, and relates this document to other EPA air toxics
guidance.  The first chapter discusses the choice of mail-out questionnaires
over other information-gathering methods.  The second chapter describes
differences in the features of various air toxics questionnaires, such as
open-ended vs. closed, emissions-based vs. chemical  use, permit related,
or general  vs. industry-specific.  The third chapter discusses the individ-
ual elements of a mail-out questionnaire: the cover letter; the instructions
for the questions; and what should be included in each. Chapter four con-
siders questionnaire design to maximize the return rate and accuracy while
maintaining a good working relationship with industry.  Follow-up procedures
are discussed in Chapter 5.  Chapter 6 gives a description of various state
agencies and their development of air toxics inventories.   Appendices include
sample air toxic questionnaires which were gathered  and selected from a re-
view of sixteen state and local agencies.  The questionnaires represent six
different types of questionnaire formats with several  combinations of each.
In addition, an USEPA SARA 313 Inventory Release Form is included in  '
                                   vii

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Appendix I.  The effective date'for affected industries to submit the
SARA 313 Form to both the USEPA and to their respective states is July 1,
19-88.  The total plant data available from these forms should provide  a
rough screening tool for potential air toxics sources.

     Although the questionnaires, instructions and cover letter presented
in the appendices were compiled from those in actual  use by several  agencies,
the agency identification information has been deleted from them (except
in the case of the Appendix I SARA 313 Inventory Release Form), often  at
the request of the agency involved.  Though the source of each is somewhat
anonymous, we do wish to acknowledge the work of the  following state and local
agencies in preparation of the examples.

     -  State of Mew Jersey, Department of Environmental Protection
     -  State of Indiana, State Board of Health
     -  Minnesota Pollution Control Agency
     -  State of California Air Resources Board
     -  State of N.C., Department of Natural Resources and Community Oevelopment|
     -  Pennsylvania Bureau of Air Quality Control
     -  South Carolina Air Quality Management District
     -  State of Maryland, Department of Health and Mental Hygiene
     -  Air Pollution Control District, County of San Diego
     -  Bay Area Air Quality Management District, California
     -  Allegheny County Health Department
     -  Lane Regional Air Pollution Authority, Oregon
     -  Maricopa County Health Department, Arizona
     -  Kansas City, Wyandotte County Department of Health
                                    vm

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                                CHAPTER  1

                               INTRODUCTION

     This document  is designed to provide  air toxics questionnaire examples
to State and local  air pollution agencies  that wish to develop or expand
their air toxics  emission  inventories.

     This document  is not  intended to be a comprehensive source of complete
air toxics questionnaires  covering every inventory situation.  Though sample
portions of many  questionnaires are included in the rather extensive append-
ices, each agency is urged to design its own questionnaires to meet its par-
ticular needs.  In  some cases a combination of features adopted from several
questionnaires may  best fit the particular program needs.  In some states a
general  questionnaire is sent first, to be followed by industry-specific
questionnaires later.  In many states however, resources and manpower may
limit the agency to one mailing.

1.1  Background

     EPA is strongly emphasizing the development of State and local  air
toxics inventories  and other data collection capabilities as part of its
National Air Toxics Strategy.  As discussed in Compiling Air toxics .Emission
Inventories (EPA-450/4-86-010). air toxics emission inventories can  be con-
ducted in one of several  ways according to the needs and resources of the
agency.   If only a  few-industries are involved, if a small  amount of informa-
tion is  needed from each one', or if written verification is not necessary,
telephone calls may suffice.  Plant visits by agency personnel  may be appli-
cable when there ane few industries or a small  geographical area.  However, •
if there are numerous industries and/or many toxic compounds covered, the
mail-out questionnaire is the most practical  method of getting the bulk
of the information  needed for starting or updating the inventory.

     Before an agency selects a certain approach, the agency should  deter-
mine whether it has the manpower and resources  to conduct screening
studies, to design the questionnaire, print it  and mail  it, to properly
review the returns  and follow-up delinquent responses,  and  finally to
compile  and analyze the results.  No one questionnaire format will  be
suitable for all  of the different agencies' needs.  Depending on the
particular State's mix of industries; it may be best to use several
different questionnaire design approaches to  get an exact match with  the
agency's needs.

     Once effective questionnaires  are adopted  that meet these agencies'
needs, it is desirable for them to  adopt a policy of minimal  change  so
that respondents can become familiar with the form and  make less errors
when completing it  for future updates.

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      In  all  cases, the  psychological  impact  inherent with answering any
questionnaire and the ongoing  relationship with the recipients must be
considered.  Future questionnaire  responses  may be affected by the consid-
eration  with which the  present  survey is  conducted.  Similarly, past
agency experience  should  be  factored  into the  current design ef ,ort.

1.2   Technical  Approach

      Chapter 2  of  this  document addresses considerations  that must be
taken into  account when developing questionnaires.  These include the
uses  of  the data collected,  the importance  of  screening studies and the
various  ways to use  data  already available  to  the  agency  for screening
purposes,  and types  of  sources to  be  included  in  the  survey.   In  addition,
a discussion is included  concerning required SARA  313  Inventory Release
Form  information,  which in the future will  provide  new  capabilities to
States  for gathering a  variety of general  information  on  over  300 compounds.

      Chapter 3  describes  the basic elements of an  air  toxics emission
 inventory  mail-out and  discusses what should be included  in  each, including
 the cover letter, the general  instructions   for completing tne  survey,  ana
 specific instructions of importance.   Chapter 3 also  includes  discussions
 of the various  approaches available when designing air toxics  questionnaires.
 These include  discussions characterizing the various  example questionnaires
 that can be found in the Appendices  (e.g. open-ended  vs.  closed,  emissions
 based vs.  chemical use, permit related, general vs. industry-specific).
 Advantages  and  limitations of particular types are discussed.

      Chapter 4 addresses several  points which should be considered  in-
 order to deve-1 op a successful questionnaire effort.  Return rate  and  •
 accuracy are emphasized.  Such topics are discussed as choosing the  right
 questions,  the visual  impact of the mail-out package, provisions  to
, assure confidentiality, and the procedures  to best assure accurate responses

      Chapter 5 discusses  follow-up procedures such as delinquent respondent
  letters, phone contacts,  source inspections, source testing, and review
  of data by  appropriate personnel .

      Chapter 6 contains  a short summary of  some State and local agencies'
  air  toxics  programs.   Several  agencies'  development and  progress
  are  briefly described  in  this  section to provide historical background of
  air  toxics  programs  in the  country.   The summaries are intended to show
  some of the similarities  as well  as  some of the differences in various
  air  toxics  programs' use  of emissions data.

      The  Appendices  contain examples of  cover  letters, instructions, and
  various State  and local  air toxics emission inventory questionnaires, a
  SARA 313  Inventory  Release  form and  a partial  list of  required SARA 313
  compounds..

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     In all these efforts, the air toxics emission inventory development
process can be expected to have some similaritres to criteria pollutant
emission inventories.  That is, the inventories will need consistent up-
dating and refinement as the agency's air toxics program develops and
changes.  As the air toxics program needs change, the questionnaires
may need to be restructured and fine tuned, but a well  thought out initial
design will help to minimize such potentially confusing changes.

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                                CHAPTER 2

               CONSIDERATIONS FOR DE-VELOPING QUESTIONNAIRES
     Uses for air toxics data are varied.  State and local agencies can
use air toxics inventories to develop preliminary estimates of emissions
for various source categories to help understand broad emission patterns
and trends and to identify major pollutants of concern.  They may also
use their inventories to provide input to various kinds of dispersion
models for estimating ambient air concentrations around new and/or exis-
ting point sources. 'A few programs are beginning to go beyond individual
point source assessment and are evaluating the impact of all sources
(large and small) of particular air toxics in a given area.  Table 2-1 ^
lists some potential  demands that may be placed upon toxics inventories.

     Different levels of detail  are needed depending on the anticipated
uses of the inventory.  Table 2-2^ shows some of the inventory parameters
that increase in complexity as the inventory applications become more
demanding.  Because this is such an important consideration, the agency
should determine what uses the air toxics inventory will be put to at the
outset of the inventory planning process.  The important point is that
the inventory agency must be aware of all of the projected uses of the
inventory before commencing with data collection.  In general, inventory
design and data collection needs will be determined by the most demanding
applications of the inventory.  Available resources and manpower must be
considered as well.-. The following sections discuss the potential  uses of
screening studies, and methods for collecting data that may already be
available in. agency files.  Advantages and limitations of each source of
information are discussed.

     The major point to be made is that the agency must take into account
what the data will be used for in order to design a questionnaire that will
obtain the data most effectively.  In order to gain a more comprehensive -
understanding of the complexities involved in compiling air toxic inven-
tories, this document should be reviewed in conjunction with the EPA docu-
ment (EPA-450/4-86-010) entitled Compiling Air Toxics Emission Inventories.

2.1  Screening Studies

     Prior to developing and mailing  a questionnaire package,  screening
studies can be done.   The primary reason an agency may decide  to perform
a screening study is to develop preliminary estimates of emissions and
associated risks before conducting a  mail-out to industries.  Screening
studies can help to define how the air toxics questionnaire should be
designed.  In other words, the screening study may indicate an air toxics
concern in a certain region, or for only certain pollutants and source
categories, or may indicate the ability to use permit information  that is
al ready available.

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                                TABLE 2-1
            POTENTIAL DEMANDS UPON AIR TOXICS EMISSION INVENTORIES


1.  Satisfy a legislative or other mandate.

2.  Identify sources and general  emission concentrations, patterns,
    and trends.

3.  Store data from related programs.

               e.g. — permit/registration/compliance data
                    -- emergency preparedness data
                    — right-to-know data
                    — act as "tickler file"* for permit review and
                       enforcement actions

4.  Site ambient air monitors.

5.  Provide input to point source dispersion models to predict ambient air
    levels.

       e.g. — to compare with .acceptable ambient air levels (AALs)
            — to determine maximum individual risks and aggregate
               i nci de nee.

6.  Focus subsequent inventory work or other program development efforts.

7.  Identify multiple source and multiple pollutant problem areas
    characterized by high additive risk.                •

8. Develop control strategies, risk management, and regulations.
Note:  This list  is not intended, to be all inclusive.  It reflects uses
indicated by various State and local agencies and EPA.
*Note:  A tickler file could be a file that prioritizes specific companies
based on immediate potential ambient toxic impact in the case of an
accidental  release of certain chemicals.  These companies could be targeted
(depending  on compliance records) for more frequent or more extensive
agency  i ns pect ions.

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                                TABLE 2-2

            INVENTORY COMPLEXITY AS A FUNCTION OF APPLICATION
     INVENTORY USE
LESS DEMANDING APPLICATIONS
MORE DEMANDING APPLICATIONS
  LEVEL OF COMPLEXITY



SIMPLE DATA SUMMARIES

AGGREGATED SOURCE DATA

MAJOR POINT SOURCE EMPHASIS

MORE SOURCE CONTACTS

STACK AND EXHAUST DATA

CONTROL EQUIPMENT TYPE AND EFFICIENCY

SPATIAL AND TEMPORAL RESOLUTION

INCLUSION OF MINOR AND AREA SOURCES

CONTROL STRATEGY SIMULATION CAPABILITY

COMPLEX DATA HANDLING CAPABILITY
(Note:  Refer to Table 2-1 for various applications of air toxics emission
inventories-.  In general, the applications in Table 2-1 become more
demanding with increasing order of listing.)

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     By maximizing use of data already available to the agency (i.e.
permit file review, sorting by SIC codes, source registration review of
upcoming required SARA 313 information etc.) the number and type of
questionnaires designed may be minimized.  By reducing the request for
information a source may already have been required to submit to a State
or Federal agency, the source may be more receptive to providing a timely
and accurate response to the questionnaire.

     Results of the screening study should be made available for review
to personnel such as modelers, environmental engineers, chemists, planners,
and permit reviewers.  They can point out possible inconsistencies, short-
comings of the questionnaire design, or where certain emissions estimates
may seem inaccurate.  They may also point out where there is a need for a
more detailed study of certain sources emissions estimates, source testing,
or on-site inspections.

2.2  Sources to Be Included

     Developing an air toxics inventory involves a thorough investigation
of the local sources of air toxic pollutants.  Several methods ana availaole.
resources that can be used to identify potential air toxic sources are
described below, but a combination of research efforts may produce the
best results.'

     2.2.1  Criteria Pollutant Data Base

    -Agencies may choose to include sources currently listed in the
criteria pollutant inventory, though this inventory may not include
smaller significant sources, area sources, or fugitive emissions.
Agencies should consider certain types of small facilities such as dry-
cleaners, service stations, and area emissions from mobile sources for
air toxics  inventories, because minor point and area sources such as
these are significant contributors of solvent l.osses for a number of air
toxic compounds.  Non-traditional sources (waste oil combustion, resi-
dential wood-heaters, hospital sterlization, etc.) should be included
also.  The  other shortcoming to an exclusive criteria pollutant data'oase
approach is that only point source or stack emissions may be considered.
Air toxics  inventories may need to include  fugitive emissions from certain
types of  sources for certain compounds.  Therefore, referring to criteria
pollutant sources can provide a good start  in forming an inventory, but
additional  research should be performed as  well, depending on agency
resources,  and the mix of  industries in a particular area.

     2.2.2  Prioritized Substances

     It may be more cost effective for the  agency to prioritize certain
sources based on substance toxicity, and substances listed under NESHAPS
or NESHAPS  candidate substances (EPA Document 340/1-85-006).  In addition,
Chapter 5 of Compiling Air Toxics Emissions Inventories details several broad
source categories that may account for a rather large fraction of air toxic
emissions.  This approach-may work well for an agency with limited resources
that is developing a first inventory.  Further, sampling of some area
sources and source inspections and/or testing can pinpoint air toxics
emission  sources for certain localities or  geographic areas.

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     2.2.3  Selected SIC/SCC Codes

    . Toxic Air Pollutant/Source Crosswalk is a compilation of tables
which associate potential  air toxic pollutants to sources by Standard
Industrial Classification  (SIC) codes and by Source Classification Codes
(SCC).  Although not an exhaustive list of compounds, "Crosswalk" is a
valuable resource in deciding which potential  sources are'to be included
in an air toxics inventory questionnaire.  The SCC emission factors are
available to estimate criteria VOC emissions when recent source test data
is not available from a source.  This used in conjunction with a VOC
profile key along with an  apportioning factor can represent specific air
toxic compound emission factors for a wide variety of industrial  processes
EPA plans to update these  data, and further verify, and extend their
applicability as more air  toxics source test data becomes available.

     When emission factors, speciation data, or source assessment data
are not available, a conservative or worst case material balance may oe
used to quantify emissions, at least for screening purposes.  Whatever
estimating method is used, the method should be recorded so that it may
be updated when better information becomes availaDle.

     Each of these approaches to quantify air toxics emissions has
limitations and certain practical  uses.  The agency should keep these
limitations in mind when designing its own particular air toxics emission
inventory questionnaire, and when evaluating the industry responses.
These "Crosswalk" tables are. available in two forms: in a data management
system or in hard copy (EPA Document 45Q-4-.87-023a).
     Some State and local/agencies have assigned specific air toxics
emission factors in their existing criteria pollutant emission inventory
                    Other agencies input individual  emission factors on a
                     Still  others have not computerized their inventories,
                    do so in the future.
data base systems.
case-by-case basis.
but are planning to
     2.2.4  SARA 313 Toxics Release Inventory Reporting Form

     Another resource is the SARA 313 Inventory.  By July 1, 1988 many
facilities will be required to complete SARA 313 Inventory Release Forms.
Working from a list of 329 compounds and groups of compounds,  extensive
sources will be covered. This new resource will help states to identify
affected sources, pollutants being emitted, and estimates of total  plant
emissions, etc.  It will not, however, provide individual stack data,  the
size of sources, or plant layouts. The industry must provide total  plant
estimates of point-source and non-point source (fugitive) air emissions.
This information should be useful as a screening tool  to target potential
air toxics hot spots, or to help select what air toxics pollutants to
include in the inventory, permit program, or source registration process.
A copy of the 1987 (Emission Year) form is provided in Appendix I.

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     2.2.5  Use of Permit Programs For Air Toxics Updates

     Many agencies use their established new source review and operating
permit renewal programs as a source for inventory update information.
Some agencies directly incorporate certain permit conditions, such as
allowable emissions, into the emission inventory.  A short-term dis-
advantage of this process is that many States require permit renewals
only once every 3 to 5,years, so the inventory could take several  years
to complete in this manner.  Also only a few toxic compounds may present'
be regulated such as NESHAPS, and information inay be needed on a mucn
broader scale, depending on the intended use of the data.  To develop a
comprehensive plan for air toxics,, the agency will not likely wish to
wait 3 to 5 years for an accurate air toxics picture for their State or
local area.  Even if they use this process, they will need to supplement
it with information from other sources such as those covered  by NESHAPS
and compounds of local concern.

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                                CHAPTER 3

                      AIR TOXICS EMISSION INVENTORY
                          QUESTIONNAIRE ELEMENTS
     An air toxics emission inventory questionnaire mail-out has three
basic elements:  the cover letter, the questionnaire instructions, and
the questionnaire itself.  As previously discussed in Chapter 2, the
questionnaire format and content depends on the detail  of the inventory
and the ultimate use of the data.  All of these components, when considered
together, make up the air toxics questionnaire package.

3.1  Cover Letter

     The cover letter is a key to the air toxics emission inventory, be-
cause it introduces the purpose of the questionnaire and is the initial
contact with the recipient.  If the cover letter does not command atten-
tion, the attached questionnaire may be discarded or filed away and not
considered a top priority.  Th-is could make the number of companies
requiring recontact by agency personnel increase dramatically.

     The cover letter should include:

     o  Applicable regulations, if any, that require the recipient to
        respond and appropriate penalties;

     o  Confidentiality provisions, if applicable;   •            .

     o  The purpose of the questionnaire;

     o  A respectful  request  for cooperation in filling out the
        questionnaire;

     o  Due date for the return of completed questionnaires;

     o  An agency person who  can be contacted for questions.

    • o  Rationale for asking  what may appear to the source to be redundant
       information.

     The cover letter should  be as short  and direct as  possible.  Some
example air toxics cover letters are included in  Appendix A.  The most
successful return rates for questionnaires  have been the ones having  the
strongest legal  statements.   Therefore states requiring air toxics  source
registration to  obtain  construction or operating  permits may obtain better
source cooperation.  If no specific air toxics regulations have  been
adopted yet, then regulations  pertaining to  particulates or volatile
                                    10

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                  so it will
                to begin for
be
tardy
organic compounds can be substituted.  Or, the State or local  agency can
require sources emitting certain substances to fill  out registration
information in order to obtain operating permit renewals or construction
permits.  The State or local agency may have a General  Statute that grants
them the legal right to ask for information from any source under their
jurisdiction.

     The final due date for returning the questionnaire may be specified
either by a certain date or as a period of time after receipt  of the ,
questionnaire.  The agency should record each due date
clear when follow-up letters or phone calls may need
respondents.

3.2  Questionnaire Instructions

     General  information that affects the whole questionnaire may be
included first on the instruction page.  For example, if the questionnaire
is "open-ended" (i.e., asks the recipient to list every texic compound
from every emission source), it should  be clear that the respondent
should use chemical compound names or preferably CAS numbers and not just
industrial trade names.  Also, it may be helpful to point out that not
al T questions, sections, or pages may apply to every industry,_as in a
source category specific directed questionnaire.  If the question pages
are designed  for direct coding to computer input, the general  instructions
should explain how to enter numbers  properly.  In addition to explaining
how to complete the questionnaire, the  general instructions should indicate
the specific .year, or other appropriate period of time, for which-all
data are  required.   -                                         •

     Some  agencies have utilized production/use questionnaires which
basically  just ask sources  to identify  whether each substance is purchased,
used,  or  produced, followed by a more detailed questionnaire-to  specific
targeted  industries.  Some  agencies  include minimum usage or  emissions
levels  specified on  an  attached list as part of the instructions.  Examples
of air  toxic  questionnaire  instructions are included in Appendix 3.

3.3  Questionnaire Design.

     There are several  ways to  design  a questionnaire.- Of  utmost impor-
tance  when designing  a  questionnaire is that the  format suits the needs
of the agency and  attains  correct-responses and maintains  a good  agency-
industry  working relationship.

     Several  approaches can be  taken in designing the  questionnaire which,
in turn,  will effect  the  format of the  questionnaire.   The  approaches
that can  be  used include:  open  vs. closed-ended,  emissions-based  vs.
 chemical  use, permit  related, and  general  vs.  industry-specific.   In
 order  for an agency  to  decide which  approach to use  it needs  to  be  familiar
with  some of the  impacts  of each  approach.
11

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     Examples of questionnaires designed for different approaches are.
included in Appendicies C-H.  These examples were taken from agencies
that have used them already in developing air toxics inventories.  These
sample cover letters, instructions and questionnaires "are examples only
and are purely to provide guidance.  They are not to be reused and are
not endorsed or recommended for use, nor" do they represent flawless
examples.  Each agency should tailor their inventory package according to
their agency's individual needs.  Many times, the examples are a combina-
tion of approaches.  For instance, in one case a general  design question-
naire was sent to various manufacturers and process industries, and
later, industry specific questionnaires were sent to a small  subset of the
original  recipients.  In still another case a screening study was first
done to narrow down the number of sources to be inventoried and indicated
the design needs of the final  questionnaire to be sent out; later, a
second questionnaire was sent.

     The following sections explain the advantages and disadvantages of
various type questionnaire designs.  These are not necessarily mutual ly
exclusive.

     3.3.1  Open-Ended Approach

     The open-ended approach does not target specific source types or a
limited group of compounds.  The open-ended approach asks, the respondent
to list any compound that they emit.  It does not provide a checklist of
compounds.  Therefore, with an open-ended approach a much larger number
of contacts will  be necessary.  This approach has several  .similarities to
a screening study:

     o. less time and effort in questionnaire design;.   .

     o  responses may be less  detailed;

     o  more responses may be  inaccurate or trade names may be listed;

     o  some sources may report no air toxic emissions.

     (No agencies reviewed by  this effort use this approach).

     3 .-3 .2  Closed-Ended Approach

     The closed-ended approach (see Appendix C)  is a more directed approach,
which usually provides a limited list of compounds with the questionnaire.
Some agencies'  lists of compounds are becoming rather extensive and use of
CAS numbers are widespread.  This approach requires more  design time up
front (e.g. screening studies, modeling  analyses).  However,  the benefits
are that the resulting number  of sources contacted can  be  greatly reduced
and the quality and detail  of  the data received are usually better.  As
the lists grow, computerized data handling becomes a necessity.

     3.3.3  Emissions-Based Approach
as
  Emissions-based questionnaires request information often included
annual  volatile organic compound (VOC)  or particulate matter emissions.
                                    12

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The agency may request permitted or potential  emissions per source and/or
actual emissions, average emissions, or emissions per day.  They may also
specify emissions per hour (or time, interval)  -for specific compounds.  In
many cases some of this information can be collected for the majority of
sources from the established criteria emission inventory records.  The
agency may also ask for emergency episode emissions, fugitive emissions
and information from excluded criteria emission inventory sources.
Unless source test data are available, it may be better to get VOC and PM
emissions from the source and have the agency personnel apply apportioned
emission factors from references they select to insure consistency or to
be used to cross-check emission rates supplied by the source.

     3.3.4  Chemical Use Approach

     Chemical use questionnaires are directed toward lists of specific
compounds and ask for process input information and Material Safety Data
Sheets.(MSDS).  The Material Safety Data Sheets include the needed species
composition data and should be requested where available, for any approach
used.  The agency can require the source to contact the suppliers of
chemicals they use, if MSDS are not available.  The agency can use-these
data if information is also provided on daily use, process operating
parameters and efficiency of the control equipment to make emissions
estimates.  Emissions-based .and chemical use questionnaire examples may
be found in Appendix D.

     3.3,5  General Approach

     Examples of the .general approach to air toxics questionnaire design
are illustrated in Appendix F.  This type questionnaire may be used as
input  to simple screening models to determine if 'a particular source is  a
potential problem and if further, more detailed source, emissions, and
modeling data are required.  A list of chemicals is provided and the
source must  access  if it emits any  of the listed compounds.  These ques-
tionnaires may list minimum levels  for each compound addressed.  Such
questionnaires may  also be used in  conjunction with several source specific
questionnaires.  The general questionnaire may also be  sent to a variety
of manufacturing or industrial process facilities not  covered by the
source specific questionnaires.

      3.3.6   Industry-Specific Approach

      Included in Appendix G are examples of several industry-specific
questionnaires.  These are  very detailed questionnaires that may include
emissions information  from  process  vents, fugitive equipment leaks,
equipment openings, raw material/product  storage and handling, secondary
waste  treatment, and  liquid spills.  Questionnaires of this type are
usually  focused  on  a  handful of very large, singularly important point
sources.  A  great deal of  pre-screening  effort would be required  for
industry-specific questionnaires, and  a  great deal of  effort would also
                                     13

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be required of the recipient in filling out the questionnaire.  More
effort would be required per source for the agency to properly interpret
the response.  However, this level of detail is probably the next best
thing to actual source testing in estimating emissions.  This technique
may also prove useful in targeting particular sources the agency determines
may or may not need costly source tests.

     3.3.7  Tiered Approach ,

     Appendix H illustrates the tiered approach or staggered mail-out
approach to emission inventory source data collection.  In this case a
cover letter and screening study type questionnaire are used, followed
later by more detailed questionnaires sent to a select number or type of
sources.  A phone survey may be conducted by the agency prior to the
screening study to narrow the number of facilities to send the screening
study questionnaire or the detailed questionnaire.  Whether the phone
survey is conducted before or after the screening study questionnaire is
sent depends on the number and type of facilities in the inventory  area.
A good example would be dry cleaning establishments.  The state manufac-
turing guide may list 100 dry cleaners in a certain city.  However,  after
a phone survey, the agency found that 75 percent of these locations
are only drop-off and pickup service centers.   By conducting the phone
screening, it was obvious that no questionnaires were necessary for  chose
service centers.   A more detailed questionnaire was then sent to the
remaining 25 drycleaners.  This benefitted both the agency by not having
to review unnecessary forms, and the excluded  service centers by not
wasting their time completing unnecessary forms.  Phone screening may not
always be an efficient use of agency time, depending on the individual
agency needs or types of industries included.

     Another approach is to first send an open-ended questionnaire or
general  questionnaire, followed by later designed industry specific  (by
source type) questionnaire, followed-up by phone calls to clarify data
and/or source tests or inspections.
                                    14

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                                CHAPTER 4

                           OTHER CONSIDERATIONS

     Other considerations when developing an air toxics questionnaire are
more related to strategy- for maximizing accuracy and minimizing cost and
time involved to conduct an inventory.  These include discussions of the
importance of asking the right questions, maximizing return rates, provid-
ing for facility confidentiality of trade secrets, outlining what quest-ions
are applicable for particular source categories, designing question/answer
style and format to decrease confusion or misinterpretation, providing
written instructions for answers (especially units of measurement) with
computer coding format instructions if necessary, and developing a data
quality assurance procedure.  Some of these considerations are clearly
technical in nature, but they need to be incorporated with administrative
and procedural considerations for the whole effort to be the most efficient.

4.1  The Right Questions

     A successful  air toxics questionnaire obtains the right answers to the
right questions for the particular agency while maintaining a good working
relationship with the recipients.  Duplication of information alreaay avail-
able through permit files may not be needed if the number of sources includ-
ed in the survey is few and the information is easily extracted- from other
sources.  However, for large survey efforts, it may be too time consuming
for agency personnel  to extract needed available information, and thus, some
duplication of effort on the part of.the sources cannot be avoided.  If the
sources being sent questionnaires are the same as included in-the criteria
pollutant inventory,  all information which the agency already has about the
recipient's facility, such as mailing address, SIC number, UTM coordinates,
emission point numbers, etc., should be preprinted on the questionnaire.
The agency could use  a window envelope to expose the facility name and
address and avoid  making additional  mailing labels.

     The most profound difference between air toxics and criteria pollutant
inventories is in  the sheer numbers  of substances included.  Since there
are literally hundreds of potentially toxic substances as compared to only
a handful  of criteria pollutants, asking the right question in all  cases
can become formidable.  Also, data handling and  data collection needs
increase as more substances are inventoried.  In addition, if the emission
estimates are to be used as inputs to models, then the data must  be
collected spatially and resolved to  grid cells depending on which models
will  eventually be used, therefore the "right" questions to ask may vary.
In general  the complexity of the questions will  be determined by  the"most
demanding application to which  the inventory will  be applied.

4.2  The Return Rate

     The return rate  of a questionnaire depends  on several  factors.   The
first impression of the recipient, the simplicity of the questionnaire,  and
conveying the importance of returning the  questionnaire are all  important
factors affecting  the return  rate.
                                    15

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     4.2.1.   Minimize Questionnaire Length

     The  recipient's first  impression will  be based on the size of the
questionnaire.   It  should be as brief as possible.  Unfortunately it may
be impossible for the forms and accompanying instructions for a large
listing of toxic compounds  or source categories to be brief.  So, the
next best approach  may  be to design the  forms in such a way to make the
pages as  uncluttered and readable as possible leaving ample room for
answers.

     4.2.2.  Maximizing Return Rates

     In addition, several items should be included in the cover letter
to insure a high return rate:

     o  A statement about, any laws which require a recipient to respond;

     o  Provisions  and  procedures for confidentiality;

     o  A due date;

     o  A contact name  and telephone number to call for questions;

     o  An addressed return envelope.

     A strong statement about existing and applicable regulations  which
require a recipient to respond to the questionnaire is the agency's most
powerful tool for maximizing the return rate.  The statement should be
placed prominently  in the beginning or at the top of the cover letter.
It should cite any applicable regulations or proposed regulations  and
specify penalties for noncompliance.

     Another important  item to include in a cover letter to  ensure  a high
return rate is the due date.  The final  due.date should be included in
the cover letter so that it will not be overlooked by those  who do  not;
read instructions.  The due date may be specified either as  a stated date
or as a period of time after the recipient receives the questionnaire.
The first approach  is more specific, and gives the recipient a definite
deadline.  With the latter approach however, the questionnaire mailing
can be staggered without having to reprint the due dates listed on  the
cover letter.

     Staggered mailing is particularly important for very large inventories,
because 1000 or more questionnaires returned simultaneously  may be  too
difficult to process at one time.  Staggered return uses the_agency's
limited manpower and resources more economically.   Questionnaires  can
easily become lost or damaged if they are not processed  expediently by
the agency, and this may be less likely to occur if the  staggered mailing
approach is used.

     Each respondent should have an equal  amount of time to  respond  to
questionnaires when using the same format and approach especially  if
there is a penalty for late responses.  But  this must depend  on equal
complexity of the information required by questionnaires.  Obviously,.
                                    16

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file of general information pages.  This consideration is especially im-
portant if the agency subcontracts to a private company for the interpre-
tation and transcription of the information.  If the information is com-
puterized, the identification information coul-d be entered into a separate
limited access file.

     Each'agency should be versed in their local laws to ascertain that
the concealment of identification is not forbidden (the public access to
records varies among states).

     A system which allows for partial confidentiality could be established
in the cover letter using a paragraph similar to the following:

     "Any proprietary information, which you believe is of a confidential
nature, should be identified in a supplementary letter with applicable
data in the questionnaire marked with the word CONFIDENTIAL.  A brief ex-
planation in your letter for the desired confidentiality should be included"

     This system indicates clearly to the agency which information is con-
fidential and which is not.  It also alerts the agency to look for supple-
mentary supporting information with each returned questionnaire that is
marked anywhere with the word "CONFIDENTIAL."  However unless the marking
is very clear, this system can become tedious and inefficient.

4.4  Applicability and Clarity of Questions

     Several factors in the design of the question section can determine
the efficiency of the mailing and affect the return rate as well.  First,   .
there should be a clear statement- from which the respondent can. determine
whether the questionnaire is applicable to his facility.  Second, the
questions should be wel1-arranged and easy to answer.

     A clear statement of applicability serves several purposes.   If the
questionnaire  is applicable, the  statement reinforces the necessity of
compliance.  If the questionnaire is not applicable and recipient can
easily determine it as such, he may be more cooperative in the future
when the questionnaire does apply to him.  A'maximum return rate for;
non-applicable respondents is important because the agency will not have
to waste time and money for follow-up and know up front which facililties
are not being  inventoried.

     The  use of a check box for-applicabi lity will help the agency
distinguish- between questionnaires that are not applicable and the ones
that are  returned without any response.  Examples of statements of ap-
plicability are provided below.

     o   If  this equipment was used -at least five  (5) days last year,
         check  this box and complete the questionnaire.               '

     o   If  this equipment was not used at least five (5) days last year,
         check  this box and return this form.

     o   If  this equipment has been removed, check this box and return
        this form.
                                     18

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     o   If  the  compound use  on  the  attached  table  is  less  than  the
         minimum  level  listed, check this box and return this  form.

     Statements  of non-applicability at the  beginning of each page or
section  can be used as an alternative or supplement to a general statement
of applicability.  Colored pages may be used to designate  different
sections of the  questionnaire.  By supplying a check box,  the agency can
'discriminate between pages which were forgotten and which  were  not appli-
cable.

4.5  Complexity  and Questionnaire Format

     As  mentioned earlier, the questions must be well-arranged  and easy
to answer.  Brevity enhances the rate of return.   The agency can usually
reduce the bulk  of the question section by designing industry-specific
questionnaires instead of general questionnaires.  Industry-specific
questionnaires are designed specifically for one particular industry, as
opposed  to general questionnaires applicable to a whole group of industries,
For example, it  may be better to send an industry-specific questionnaire
to a dry cleaning establishment and a multipage, general  questionnaire to
an organic solvent user.

     The consideration of questionnaire format, however,  must be balanced
against  the level of resources available to  the agency conducting trie inven-
tory.  It takes  more money and manpower to design, mail  out, and interpret
industry-specific questionnaires than it does general  questionnaires.  Pro-
cessing  of industry-specific questionnaires  is also more complex because
the format of each questionnaire will  vary.  Furthermore,  it is possible
to send  an inappropriate industry-specific questionnaire to a facility.
On the other hand, general questionnaires may be preferable if.the agency's.
resources' are limited or if the agency is unfamiliar with many of the
sources.  Inventories for specific pollutants may be most  advantageously
conducted with general  questionnaires.  Furthermore, general questionnaires
may be more appropriate for large or complex facilities  that are difficult
to. characterize.  Most of these facilities will have engineers available
to translate their process and emission information onto  the forms.

     If  a general questionnaire must be used, it is important to provide
a statement of applicability for each  page.  In addition,  questionnaires
that are organized so that all information about each  emission point can
be provided on one page are usually easier to fill  out than questionnaires
that have separate pages for process,  emissions, control  equipment, and
stack information (subject-by-subject).  For this reason,  source-by-source
questionnaires are usually considered  the better format.   However if the
questions are arranged  by subject,  industry-specific questionnaires can
be designed by simply selecting the subject  pages that apply to each
industry.  Then only a  few supplementary pages  of questions that are
unique to an industry must then be  formulated.

     Another method that can minimize  the level  of effort  required from
the recipient, and therefore enhance the return rate,  concerns the format
of the questions.  Multiple choice  questions are the easiest type for
recipients to answer.  Many questions  can easily be formatted as multiple
choice.  For example, a question that  asks the  recipient  to describe or

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rrame the type of control device used can be improved by supplying a list
of conceivable control devices and asking the recipient to put a check
next to the appropriate answer.  When needed, multiple choice questions
can include the choice "other" with a blank beside it for entering out-of-
the-ordinary controls.  Other questions, such as those that require exact
numerical  answers,.can only be answered appropriately with a written re-
sponse.  If there are repetitive questions, the recipient could be asked
to make a copy of a questionnaire for each point source or substance being
inventoried.

4.6  Clarity of Instructions

     To be considered accurate, questionnaire responses must provide both
the descriptive information desired and the correct numerical data.  Every
effort must be made not to confuse the recipient.  Therefore it is important
to provide clear, complete instructions to decrease the chances of error
in the responses.  Instructions should be as concise as necessary.  Units
of measurement, method of calculations and conversions, and code number
instructions should be put on_ tne questionnaire itself and not explained in
the instructions.  This enables the recipient to read through instructions
expediently without becoming  caught up in too much detail.           '

     In conclusion, general instructions should be as precise as possible.
Some of the most effective air toxics questionnaire instructions are those
wnich explain in detail how to answer each question.  If a particular; ques-
tion requires special clarification, it is best to note special instructions
on the same page- as the question rather than print them on a separate instruc-
tion, page.                      •"..'.

     The following types of information should be included when asking
detailed questions:

     o  Specific Responses — printing the type  of units wanted for an
        answer right  next to  the answer space.  Using the multiple choice
        format as discussed earlier;

     o  Samples — providing  completed samples with the instructions for
        process flow, schematic and plant  layout diagrams.  Sample diagrams
        help the recipient to visualize what is  expected; they are easiest
        to interpret  if they  are adjacent:  to the instructions;       ;

     o  Standardized  Forms ~ providing standardized forms when periodic
        inventory updates are performed.   Regular recipients will eventually
        learn  how to  provide  the correct  responses.  This is one condition
        under  which a single  generalized  form for all facilities is efficient;

     o  Emissions Estimates — instructions  for  the inclusion  of test methods
        used.  Examples of test methods include:  material balance, emission
        factors, test results, and  engineering judgments, apportioning
        should be specified.                                         ;
                                     20

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4.7  Final Considerations

     After a questionnaire is designed it is good quality-assurance procedure
to check its effectiveness.  This can be accomplished using a limited pilot
mailing followed by site visits.  This procedure provides a check on the
effectiveness of the particular questionnaire package and their applicability
to different sources.  A final  possibility that may improve industry-agency
relations would be to include a few questions at the end of the questionnaire
or on a separate page for industry suggestions for future questionnaires
or questions such as the following:

  -  Were the questions clear?
  -  Approximately how long did it take to complete the form?
  -  Were the questions applicable to your company?
  -  If you called for agency clarification, did we adequately  respond?
  -  Was the time allowed after receiving the questionnaire adequate?  If
     not, why?
  -  Please provide additional  comments,  if any.

     This type of.addition may  indicate to the recipients a true concern
to minimize industry paperwork, or at least the desire to. work  with industry
to improve future questionnaires.
                                    21

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                                CHAPTER 5

                           FOLLOW-UP PROCEDURES
     Follow-up can be as important or more important than the planning and
effort expended in questionnaire design.  The accuracy and completeness of
responses must be checked and tabulated, or entered into a computer.  De-
pending on how thorough the questionnaire instructions were explained with
the mail-out, and whether deadlines were identified in the cover letter, a
second major effort may be required to contact recipients who are delinquent
in responding or to clarify items such as emissions units or estimates of
control efficiencies.  Some second effort can be expected, either for clari-
fication of answers .or for non-response.  The following sections discuss
the importance of such follow-up procedures such as data quality checks,
the use of on-site inspections, and recontacting sources.  Questionnaire
revisions are also discussed.

5.1  Quality Control of Data

     All  the questionnaires should be checked by engineers, chemists, or
experienced environmental scientists to determine if the data provided are
reasonable.  It is helpful  to ask for process flow and plant layout diagrams
to aid in the interpretation of data.  In addition, the best quality
check would be performed by engineers or scientists who have worked in or
are familiar with the industry.   Finally, for similar processes and
chemicals', total  emissions  can be compared against each other or checked'
against appropriate emission factors to determine reasonableness.  The
extent that detailed, checks can be done depends on the resources available
to the agency, the number of sources included in the inventory,  and the
use of the data.   It is suggested to recontact a higher percentage  of
respondents that  considered their usage lower than a specified yearly amount,
or as having no toxic emissions when their SIC code would suggest otherwise.
Perhaps they only misunderstood the way the instructions were worded, -or
know their chemicals by a trade name instead  of chemical  composition.  In
any event, a follow-up call  may increase the  accuracy of the inventory.

5.2  On-Site Inspections

     For certain  sources, it may be appropriate to consider plant visits
if more specific  information needs to be obtained for a particular  program
purpose,  although this -approach can become resource intensive and time
consuming.  Another approach is to do a preliminary screening and visit a
very small percentage of facilities as part of a data quality control
procedure.  Also, it may be wise to visit a representative sample of
respondents that  checked the not applicable box, especially if the  agency
determines from cross referencing SIC code references such as "Crosswalk",
that the  source has a potential  to emit air toxic compounds.
                                    22

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     Another less resource intensive approach may be to inspect the
facility to check air toxics emission responses during the next regularly
scheduled air compliance inspection.  Most agencies periodical.ly inspect
major facilities within their jurisdiction.  The problems that.can be i
encountered using this approach is that air inspectors may need additional
training before such air toxics inspections, as most regular air inspections
may have involved criteria pollutants or at the most NESHAPS pollutants.

5.3  Recontactinq Sources

     The return rate for the air toxics questionnaires can be increased by
recontacting recipients that are delinquent in responding either by   ;
letter or by phone.  This recontact reminds them that they will not be
forgotten and may be subject to a fine, and that a response is important.
For other companies that may be confused by some of the questions, recon-
tact provides them with a less embarassing way to ask questions.  This
interaction is the most effective while the questionnaire is being inir
tially completed, rather than having to return questionnaires to the in-
dustries for corrections.  Using a pilot mailing will help get an idea^ of
the average time recipients take to respond and how many recipients will
need to  be  recontacted.  In addition a pilot mailing can provide an
overview of the effectiveness of the questionnaire before the final mailing
is done.  Unnecessary recontacts should be minimized to avoid the poss;i-
bility of some firms becoming uncooperative.   Inventory efforts, after,
all, are not a one-time need.  Yearly updates may be necessary.

5.4  Revising the Questionnaire

     The process of revising the questionnaire"should be an evolving pro-
cess.  With each mail-out or updating of the inventory, the questionnaire
or  instructions  for completing the questionnaire can be fine tuned or re-
directed to meet the developing air toxics  program needs.  But, as mentioned
before,  industry will become familiar with  questionnaire format that is
not changed drastically from mailing to mailing.  So, a carefully considered
initial  design is the best  approach, and will  reduce time needed for follow-
up.                                                          •

     Some  changes can be expected, such as:                           '

        o  Promulgation  of new air toxics regulations, stricter source ,
           registration  requirements, or changes  in  reporting requirements;

        o  More EPA  approved emission factors or more available stack
           test, data;

        o  Increases  in  the  number and types  of compounds  included;

        o  Changes in  format of questions when  agency installs  or  changes
           its data  handling system;

        o  Changes  in  air  toxics control technology  and/or  control  equipment
           efficiency.
                                    "23

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     Other changes may be made because of the widespread occurrence of
wrong responses to a particular question.  Still another kind of revision,
but one that has as much impact, are changes in various aspects of the
inventory process, such as:


       o  Addition or deletion of the use of screening questionnaires;

       o  Changes in the cover letter, insructions or confidentiality
          provisions;

       o  Changes in the type questionnaire, such as a change from open-
          ended to industry - specific questionnaires;

       o  Changes in the ways that the agency intends to use the data;

       o  Changes in agency budgets and/or resources .and manpower available
          for inventory efforts.

     Perhaps the best way to. proceed is not  to  plan in terms of  needed
air toxics emission  inventory questionnaire  revisions, but  to continually
focus on needed improvements, whatever the reasons  turn out to be.
                                   24

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                                CHAPTER 6

                          VARIOUS STATE PROGRAMS
     Several states have already begun to develop air toxics inventories.
Following are various descriptions of nine state or local programs.  'The
intent is not to suggest that these are the only existing air toxics pro-
grams or that their approach is necessarily the best or only recommended
approaches.  Discussed below are certain programs development, uses of air
toxics data gathered, uses of screening studies, numbers of chemical com-
pounds considered, and use of prioritized chemical  and source lists.  The
similarities and the differences mentioned are meant to highlight the
individual nature.of designing State or local agencies' air toxics emission
inventory questionnaires.

     6.1  California

     The California Air Resources Board (CARS) works with the State Depart-
ment of Health Services to identify substances as air toxics through an
elaborate health impact assessment.  When there is  scientific uncertainty
in the health effects data for a substance, the data are submitted to a
Science Advisory Committee for review and evaluation to help determine
whether and substance should be listed as a toxic.   Substances included in
the initial evaluations were selected through a rev.iew of other available
lists,-such as the EPA' list of 37 chemicals given priority for NESHAP
study and lists developed by other State agencies.   Pollutants have been
prioritized for the toxicity assessment based on the availability and qual-
ity of toxic information on the pollutants.  Once a substance is identified
as an air toxic, the regional  agencies (Air Quality Management Districts)
are then responsible for inventorying emissions of  the substance.

     The South Coast Air Quality Management District.(SCAQMD) identified
30 compounds in their 1987 inventory.  A closed type questionnaire including
a list of 22 compounds was initially used to gather emissions information
which was later updated and used in risk assessment and modeling.  These
compounds are currently being evaluated by the State Department  of Health
Services to determine threshold limits.

     The Bay Area Air Quality Management District (BAAQMD) is in the
process of preparing an inventory of every permitted source in the Bay
Area.  This includes approximately 20,000 sources.   Working from a list
of 50 substances, sources were first screened.  Emitters and nonemitters
were identified and emitters were issued a second questionnaire  to quantify
usage of any of the 50 substances.  In addition, sources which are still
questionable as to  being emitters are under further research.  The completed
inventory is expected to have  emission estimates for all known sources.
These will  then be  used for modeling and prioritized to aid and  accelerate
regulatory processes for high  priority substances and sources.
                                    25

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     6.2  Maryland                                                   ;

     Maryland started a state-wide Toxic Substance Registry in 1983 Which
contains throughput emission information.  In 1985 the information in the
Registry was updated and compiled in an on-line computerized data bas;e.
Maryland includes 275 chemicals in their registry.  The information ijs being
reviewed by the Air Management Administration to draft air toxic regulations.

     6.3  Minnesota

     Minnesota has inventoried 42 substances and uses the inventory to iden-
tify what toxics are emitted in the state.  The inventory was also us:ed
to prioritize the sources according to the magnitude of toxic emissions.

     6.4  New York

     In-New York, the State Bureau of Air Pollution Control has developed
an inventory of 3,000 substances for every source that emits an air pollu-
tant.  Each substance identified by an applicant is included in the New York
toxic emission inventory.  Data are collected annually through the State's
permitting process which requires all point sources to apply annually for
renewal of their operating permit.

     6.5  North Carolina

     North Carolina's Air Toxic program sent out 3,000 questionnaires in
1986 to major and minor facilities emitting air pollutants.  The question-
naires are being used to determine the usage of 128 toxic compounds, i A
closed type survey with minimum limits for each.substance was formulated
to serve'as screening for trace emitters.  Companies which produced emis-
sions over the trace amount given for that compound were asked to estimate
emissions.  Telephone calls were made to expedite the return of all the
outstanding questionnaires which were sent out.  Draft regulations called
Acceptable Ambient Level or AAL regulations are nearing the final stages
for approval (expected to be in the Spring of 1988).  In the future, addi-
tional plant specifications and information-wi 11 provide the agency with
necessary input for models to determine compliance with the AAL regulations.
A series of modeling procedures will be performed and the AAL will oe the
basis for deciding whether sources will need to better control their emis-
sions.

     6.6  Pennsylvania

     The Pennsylvania Bureau of Air Control has begun an air toxics emis-
sion inventory for 38 substances.  As a first step, a screening survey
was used to help the State focus their inventory efforts.  The screening
survey was designed to collect basic, mainly nonquantitative data on :the
type of substance used, stored and/or emitted.  Completed questionnaires
were returned by about 90 percent of the 700 facilities to which question-
naires were sent.  This original list of facilities was streamlined to
include 300-400 companies.  These companies were sent follow-up surveys
requesting quantitative emissions data.  The information was compiled and
put into a databank.  In the future the information will be prioritized
and used for modeling purposes.
                                    26

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     6.7  Rhode Island

     Rhode Island started developing an Air Toxics  program in 1984.
Approximately 500 potential  sources were polled using a closed type
questionnaire including a list of 125 chemicals.  The questionnaire  was
developed using ideas obtained from other States'  surveys.  The Rhode
Island survey was designed to be as simple as possible to fill out.   The
substances were selected from other State lists and carcinogenic chemical
lists.  The Northeast States for Coordinated Air Use Management Council
(NESCAUM) assisted .the Agency in developing the list,  which emphasized
fairly widespread industrial  substance usage in the state of Rhode  Island
as criteria for listing compounds.   The inventory  has  been used to help
draft regulations.  Air toxics regulations for forty chemicals used  in
the state are being submitted for regulatory approval  and promulgation.
                                    27

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                                REFERENCES
1.  Compiling Air Toxics Emission Inventories.   EPA-450/4-86-010.   U.S.
    Environmental Protection Agency, Research Triangle Park,  NC  July  1986,

2.  Development of Questionnaires For Various Emission Inventory Uses;.
    EPA-450/3-78-122.  U.S. Environmental  Protection Agency,  Research
    Triangle Park, NC June 1979.

3.  Methods For Pollutant Selection And Prioritization. EPA-450/5-36-Q10,
    U.S. Environmental Protection Agency,  Research  Triangle Park,  NC  duly
    1986.
                                    28

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                                APPENDICES
     Appendices A through I contain samples  of several  agencies'  air  toxics
emission inventory questionnaire cover letters,  written instructions,
various style main questionnaires,  and preliminary  screening  or follow-up
questionnaires.  It is hoped that by providing a variety  of currently
used formats, each agency may better design  a  complete  inventory  package
to suit specific needs and help in  the development  of each changing air
toxics program.
                                    29

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                                APPENDIX A

                          EXAMPLE COVER LETTERS.



                                Statement

     The following sample cover letters are examples only and are purely
a resource of information.  They are not to be reused and are not endorsed
or recommended for use, nor do they represent a perfect example.  Each
agency should tailor cover "letters according to the specific needs of the
area.
                                   A-l

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 Gentlemen:

           The Air Pollution Control 'Division (APCD)  of the       ',
 Board of Health seeks  to protect  your health from haraful sufastanpas
 emitted into the atmosphere.   Because of the growing concern aver^ the
 potential health effects of toxic compounds, particularly those related
 to cancer, this "agency is conducting a survey to  help determine if a
 condition of air pollution  exists.

           In order to help  us  estimate che  potential for  cancer risk ir.
 your area, please complete  the enclosed  form and  return it to 'the APCD
 within TEN DAYS.  For each  compound used* state the  quantity and the
 emissions.  Confidential data will  be  handled "in  accordance' vith
 established legal procedures.  If you  think other chemicals on your
 plane property may be a potential health risk, please  list them along
 with the data at the bottom of the  fora.  If you  do  not use* any of
 these compounds, please so indicate  on the  form,  then  sign,  date/ and
 return it to  the APCD.   It is important that  you  raturr. the
 questionnaire even if no compounds are used.  This will aid our planning
 and remove your company from our list of potential sources.       :     '

                 •  Code  ^-L-l-ACB)(3) permits the State Co request  this
 type of  information.   If you have any questions or problems  in
 completing the  questionnaire, please contact  the  inspector at either  the
 address  or telephone  number below.  Your cooperation" is appreciated.

                     Return Questionnaire to:
                                    Very.. truly_ yours,
*Stored, transported, transshipped, generated  as  a  product or by-
 product, consumed in'production, lost:  to  the  atmosphere or waste
 stream, reclaimed, repackaged, or otherwise handled in some fashion,
                  1881 -A CENTURY OF Si-RVICE - 1981

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! COMPANY !
! ADDRESS!
!C!TY!
!STATE!
! Zl P !
D ea r  S i r 3:  '

      As  you probably  know,  tha  U.S.  Environmental  Protection
Agency  CEPA3 has  just  officially  released a  list  of  four'
hundred  plus chemicals that EPA  has  identified  as  being
acutely  toxic when  released into  tha  air.

      Public concern  over  air  toxics  is very  great,
particularly in  light  of  the  chemical  catastrophe  in Bhopal,
India.   Now that  the  EPA  has  released  a  first official  list
of. acutely  toxic, ch em i ca 1 s , commu niti.esraust  conduct
comprehensive surveys  to  Identify  anyone who  produces,
processes,  transports  or  otherwise  a v 2 r  handles  any  of  these
acutely  toxic c h ami c-a i s .
       Tha                       .   County Heal th  Department
Cacting  in cooparation  with  the    •     City,         Fire
Department,         City,         Emergency  Frsp.aredna.as,  the
        Department  of  Health  an Environment  and  other
agencies}   is sending  out the attached screening
questionnaire  to  gathor preliminary  information.   The
questions  asked  generally  follow chemical  ome r go n c y
preparedness official  guidance race mm endations  of  the
EPA-.   The responses  provided
with  other involved  agoncias.
                        this  survey w i I
                                               U.S.
be shared
      The  questionnaire lists each  of  the  EPA  identified
acutely  toxic chemicals and asks  you  to mark   a  "yes" or
"no"  indicating whether your company  aver  uses,  stores,
produces,  processes,  generates,  transports, or  in  any
                                               wa y
handles  each of  these  chemicals.   Please  checkmark a
or a  "no" for  each  chemical  listed.
                                               yes
      For  each chemical  that a  "yes"  was checked,  additional
questions arc asked.   Because  of  varying  space  requirements
for  responses,  thase  questions  can  bast be  answered on blank
sheets  of papar  rathar  than on'  tha  questionnaire  itself.

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                                      P a g
However.  please be  very caro'ul  to  put  the question  number
with   your, response.   Also p. loose  indicate your  company' name
o n each  attached page.   If you need  any assistance  in
filling  out  the questionnaire, please  telephone
     andasXfor                .or
     We  are requesting  that
and  raturnod to us  by
cooperation in  this  ma tier.
please  call.
this questionnaire bo completed
               Thank you  ' o r ; y o u r
 If  you have  any  questions,
                                Sincerely,
Please  Return Survey  Response  to:i

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                                APPENDIX B

                        EXAMPLE INSTRUCTION SHEETS



                                Statement

     The following sample Instruction sheets are examples.only and are
purely to provide a resource of information.  They are not  to be reused
and are not endorsed or recommended for use, nor do they represent flaw-
less examples.  Each agency should tailor instructions to the specific
questionnaire used.
                                   3-1

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        INSTRUCTIONS FOR COMPLETING CHEMICAL INVENTORY REPORT
I.
GENERAL INSTRUCTIONS FOR COMPLETING PARTS I, II AND III
      A.
      B.
      C.
    The ^formation to be reported pertains only to the chemicals listed in Table
    1 (attached). If your plant does not use, produce, or handle anv of the
    chemicals, either as a pure substance or as part of a mixture o'r does so in
    quantities identified as exempt in Appendix A, only Part I need be
    completed.  The term "handle" includes the generation or handling of :the
    chemical as a waste or as part of a waste.


    Part ffl of the questionnaire is to be completed if the chemical is stored in a
    tank.  If the chemical is part of a waste, the tank questionnaire is to be
    completed only if the waste is stored in a tank on site.
               the State.
                   na, seParate survey Package for each plant location on ! file
                   Please file a separate complete report for each location   A
              f     ^ each.location means a separate chemical questionnaire
   completed for each chemical and a separate questionnaire for each tank.

   The completed forms are to be returned to:
         If you use a messenger service, deliver the forms in person or reauire
         additional forms, contact:        .
     D.
    E.
    F.
                                                              f°r Which
  Complete all sections of the report that pertain to your firm or plant site  If
  a section does not apply to your operations, write "NA" for "not applicable."

  Attach process descriptions, explanatory notes, flow charts, lists, etc  that

  fWurth^vnT Clat-ifyinl ef?ieS made °n the reP°rt if the answe .''require
  S2S M  P lanaj10"-  SuPP^ pa&e numbers for this material.  If information
  needed to complete a section is not readily available, provide a written

                           nature of th* operations

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       G.   Use existing or readily ascertainable data to complete the Chemical
            Questionnaire. Where quantities can be determined from existing records
            (e.g., inventory or production figures) or the cost of testing is nominal, actual
          .  ngures are to  be supplied.  Otherwise, use engineering estimates *nd
            computation; process material balance studies; field tests or measurements
            made by the plant, equipment manufacturers or government agencies, or
            other technically sound bases.

       H.  If you do not know the formulation of trade name products used in plant
           operations, make reasonable inquiries of suppliers or manufacturers" to
           ascertain whether the material contains any of the selected chemicals.  'For
           example, Tri-Clene, a solvent, is a  trade name for trichloroethylene, a listed
           chemical.)

       I.    List ail quantities of chemicals unless the quantity is less than the minimum
           established in Appendix A.

II.     SPECIFIC INSTRUCTIONS FOR COMPLETING PART II

       question 1 - Indicate the name of the chemical and its CAS number.  The CAS
       numoer is found in Table I.

       Question 2 -Describe how the chemical  is used, produced or handled. Use of the
       chemical reiers to its use as a pure component or as a part of another material.
      the cnemical is used :or more than one purpose or exists in more than one *crrn
      proviae all pertinent information relating to the chemical.               "    '

      Example:  Trichloroethane may be used as a solvent in a production process and
                may also be used as a metal degreaser in some other part of the
                operation.  •           '                    •   •

      T°-u,tstio" 3 T This ?art is to ^ completed only if the chemical is brought on site
      If the chemical is used as a raw material or is otherwise brought on to the sit* *s
      a pure Component or a mixture, so indicate in the first block and indicate how" it is
      transported to the site.  If transportation involves more than one method, indicate
      for uhe year the percent use of each method.  If it is stored in a oerman-nt
      stationary storage tank or drum, so indicate. The method of storage is "othe-" if
      the chemical is stored in any portable container other than a drum or ?f ;t is "
      stored and used directly from a railroad car, tank truck, or other oortable
      container.  If it is not stored on site, indicate "none" in the "other" block  The
      maximum amount on site at any time is the maximum  amount in inventory at anv
      time.  Annual amount is the total throughput of the material for the calendar   "
     year  When reporting a mixture, indicate the total amount of the mixture in'

                            is stored on site in a tank ic fa nec      to
                                                                            Tff
                                                                            ii.
Question 4- If the chemical is produced or generated on site as a by-product or
waste on site, its handling should have been described in Question 2  In
S?™Se5S 
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        If the chemical is an intermediate that is not stored longer than 24 hours and is
        used to produce a final product that does not contain the chemical, the method of
        shipping and storing would be indicated as" none.

  HI.    SPECIFIC INSTRUCTIONS FOR COMPLETING TANK QUESTIONNAIRE

             The tank questionnaire consists of seven parts.  Answer each part in full as
        instructed below.

        question IA - Indicate the name and address of the tank manufacturer and what
        year the tank was instaUed at this site. Also indicate whether the tank was new
        or used when installed.

        Question IB - Indicate the professional ASME codes that the tank meets and check
        any other applicable codefe). Codes are defined in current ASME, NFPA  API etc
        publications. If your code is other than those listed, then specify in the space'
        provided.  Check all items which describe material of construction, method of
        construction, orientation, and roof type, and give the tank's loading capacity.

        Question II - Indicate  the tank function as "storage" if it is used solely to stbr- a
        chemical and there is no blending, reacting, etc. involved.  The tank is
        'processing" if it is used to blend or mix substances including a listed chemical
       The tank is "other" if it is part of a process and used more as a temoorary holdm-
        tank for intermediates and other process material. A reactor is not a tank. !

                  -In this part, provide information with respect to tank conditions and
       the method of transferring the chemical to and from the tank.

       StetwnlV - Indicate all devic'es used for corrosion and spin control. In addition,
       give the date that tank was most recently tested, if 'ever, and the method used.

       Question V- Describe' the security that you have specifically for the tank beino-
       reported. If the property is enclosed with a fence and the tank is within the;  °
       enclosed area, indicate "fence.". If you have a security guard stationed at the
       gate, indicate both "fence" and "staff" or "contractual" security.

       Question VI - List all current permits that relate  to the tank and chemical beins
       reported.                                                                 s

       Question yn- The questionnaire is to be completed for waste materials  onlv'if the
       waste includes a chemical listed in Table 1 and only if the waste is storeTOT'a
       tank.  Report the composition of the waste and the total quantity (pounds)   :
      generated for the reporting year.

IV.    CONFIDENTIAL BUSINESS INFORMATION

      i,    tf any question requires you to submit information which is (or would lead a
      knowledgeable reader to deduce from it) a trade secret, proprietary business
          ma   " ^."^rmation Delated to national security, make a confidentiality
               th  TU *IT trSat thSt informati°n w  confidential and not disclose t in
                ,   "I     TSal ^e Secret or Proprietary information, unless the
      Department  makes a formal finding that the material is not entitled to
      confidential treatment as provided by    .     law.  Unless  an emergency (such
      as fire in your plant which threatens to expose nearby residents to toxic  materials)

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calls for the immediate release of information, you will be notified in advance if
the Department intends to disclose information that you have claimed as
confidential. You-wiU be given an opportunity to challenge the Department's
decision through administrative processes, and if not satisfied with the outcome,
you will be given time (except in an emergency situation) to obtain a restraining
order from a court, if you wish to pursue an appeal.

To make a confidentiality claim for information reported you must:

A. Submit two  copies of the report. The first must contain all the information
   requested. The second should contain n£ information which you believe is
   entitled  to confidential treatment. (The second copy can be a photocopy of
   the first with the confidential material blanked out.)

B. Print, in red ink, at the top left  corner "CONFIDENTIAL."  Also, if desired
   mark the top of each page containing confidential information with the
   heading "CONFIDENTIAL" in large bold type, stamp or hand lettering.  Do not
   mark every page, only the ones that contain confidential information.

C. Identify all information which you claim  to be confidential by underlining or
   highlighting it in a clear manner. Translucent ink nrarkers are accepcabie for
   this purpose.
                                                            140,500  j  ibs/yr.
    Example:  Question 3:  Quantity Consumed On Site =

D.  Seal the copy of the report which contains confidential information into an
    envelope, and mark the envelope on both sides with the word "CONFIDENTIAL"
    in bold.type, stamp or hand lettering. Place this' envelope, together with the
    second (non-confidential) copy of the report, inside another envelope for
    transmittal to the Science and Health Advisory Group (SHAG).

E.  Send the complete package to   ,  J at the address listed in Item I. For your
    protection, we recommend the use of certified mail, return receipt requested,
    a messenger service, personal delivery,  or other  means that will give you
    verification that your material has been received.  You may use ordinary mail,
    but  '•    assumes no responsibility for  materials' not signed for until actually'
    received.

    Please give careful consideration to the material you claim as confidential.  Be
sure it really is proprietary or a trade secret.  Do not mark a report "Entire
Contents Confidential" or in some similar fashion.  Doing so  will result in refusal
to recognize any confidentiality claim, or in refusing the resort.

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                                   APPENDIX A.'

                               EXEMPT QUANTITIES
1. Exempt Quantity for Class I Chemicals               '                     i

   Report on the selected chemical if the total annual quantity exceeds 2.2 pounds per
   year. Report on a mixture if it contains greater than 0.1% of the chemical and! the
   total weight of the selected chemical in the mixture  exceeds 2.2 pounds.

2. Exempt Quantity for Class II Chemicals

   Report on the selected chemical if the total annual quantity exceeds 500 pounds per
   year. Report on a mixture if it contains greater than 1.0% of the chemical and:the
   total weight of the selected chemical in the mixture  exceeds 500 pounds.

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                                APPENDIX C

                      EXAMPLE CLOSED QUESTIONNAIRES



                                Statement

     The following sample questionnaires are examples only and are
purely to provide a resource of information.  They are not to be reused
and are not endorsed or recommended for use, nor do they represent flaw-
less examples.  Each agency should tailor questionnaires to the specific
needs of the area.
                                  C-l

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EXAMPLE 1 - CLOSED QUESTIONNAIRE

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                            Re:   Special Interest Substances
                                     -  Inventory Request -
Dear Sir (s) :
The     •   .  County Bureau of Air  Pollution Control is in the orccess
•of gathering information on various • substances which may be in use at
your facility.  The information gathered will be used for an Emissions
Inventory Data Base.' •               .                           •

Attached is a survey form for twenty-one  (21)  substances.   Please provide
the requested infortpation on production, usage,  sales, and emissions as
appropriate .for your facility. •

Sensitive information gathered through this inventory procedure will be
kept confidential.

Should you have -any questions regarding the above requested, information,
please call me at                   .

Very truly yours,

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                               SPECIAL INTEREST
                               SUBSTANCES   - FOR
                             CALENDAR YEAR  ^ •
     SUBSTANCE
              or
 AMOUNT  ( Ibs.—gals./yr.)
Produced        Used      Sold
   ESTIMATED
   EMISSIONS
        !or
Ibs/vr.  !— tons/*.
 1.  Benzene
 2.  Carbon Tetrachloride
 3-  Chloroform
 4.  Ethylene Oxide
 5.  Ethylene Dichiorice
 6.  Dioxins
 7.  Formaldehyde
 8.  ^Seth.yl Bromide
 9.  Methylene Chloride
10.  Perchlorcetnylene
11.  Toluene
12.  Trichlorcethylene
13.  Vinyl Chloride
14.  1,1,1-Trichlorcethane
15.  Lead
16.  Chromiurn.
17.  Beryllium
18.  Asbestos
19.  Arsenic
20'.  Ethylene Dibromide
21.  Xylene

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EXAMPLE 2 - CLOSED QUESTIONNAIRE

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                             FIGURE 1.


               POLLUTION CONTROL AGENCY:  DIVISION OF AIR QUALITY
                         SURVEY INFORMATION
 Do you work with nny
of the following compounds?
   Name oT  compound

 Asbestos
 Benzene
 Mercury
 Radlonuclides
 Vinyl  Chloride
 Acetaldehyde
 Acroleln
 Acrylonitrile
 Allyl  Chloride
 Benzyl Chloride
 Beryllium
 Cadmium
 Carbon Tetrachloride
 Chlorobenzene
 Chloroform
 Chloroprene
 Coke Oven  Emissions
 o-.,m-,p- Cresol
 n-blohlorobenzene
 Dimethyl Nitrosamine
 Dioxln
 Epichlorohydrin
•Ethyiene Bichloride
 Ethylene Oxide
 Formaldehyde
 Hfixachlorocyclopentadiene
 Maieic Anhydride
 Manganese
 Methyl Chloroform
 MeShylene  Chloride
 Nickel
 Nitrobenzene
 HIfcrosomorphollne
 Perchloroethylene
 Phenol
 Phosgene
 Polychlorinated  Biphenyls
 Propylene  Oxide
 Toluene
 Trichloroethylene
 Vinylidene Chloride
 o-,m-,p- Xylene
                                     Yes
                              No

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                        POLLUTION CONTROL AGENCY
                   DIVISION OF AIR"QUALITY
            NONCRITERIA AIR POLLUTANT INFORMATION        ;

                         INSTRUCTIONS
 1.  Company name.

 2.  Company address.

 3.  Individual  responsible for content  of form.

 4.  Emission  point ID number-  (your  company's  ID number)..

 5   Chemical  name.   A separate form should  be completed  for
    each  compound handled  (photocopy additional copies as
    needed) .

 6.  Operating schedule  when  compound used.               ;

 7.  Estimate  the amount of the material which is  handled or
    used  in  Ib/yr.

 8.  Estimate  the amount of the material which is  processed or
    produced  in Ib/yr,  if  applicable.

 9.  Emission  point  ID number (your  company's  ID number,  ;same as
     in instruction  4) .

10.   Stack or  exhaust vent  parameters.  If emissions are  ;
     released  from  building vent  without an exhaust fan,
     complete vent  height,  diameter  (or dimension  if nou
     circular),  temperature (use  room temperature), and put N/A
     in velocity and  exit  volume  spaces.  Include  velocity anc
     exit volume when exhaust fans are used.  For  all stacks or
     exhaust vents  list  actual height of discharge poinw  -aoove
     ground level.                                        .

 IT   Tnclude control  equipment for  the listed material orily;  Do
     not list a control  device unless it is effective zor tne
     listed material.                                    ;

 12   List the design control  efficiency from  the manufacturer's
     data, listing actual control efficiency  if known.

 13.  Emission point  ID number (your  company's ID number,.same as
     in instructions 4 and 9).                           ;

 14.  Describe process emitting the  listed material, using   ^
     extra pages if  necessary.  Include manufacturer and moael
     number.

 15.  Estimate actual emission rate.

 16.  Describe basis  of  emission estimate  (i.e. test  data,
     emission factors, material balance,  etc.).

 17.  List any methods employed to limit emissions  not  exiting
     through stacks  or vents.

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EXAMPLE 3 - CLOSED QUESTIONNAIRE

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                          PART I:  GENERAL INFORMATION
 1.   COMPANY NAME
 2.   COMPANY STREET ADDRESS	

 3.   CITY	4. COUNTY.
          5. ZIP CODE
 6.  PREVIOUS COMPANY NAME (IF ANY)

 7.  PRINCIPAL CONTACT  	

 3.  TITLE  •     	
 9. TELEPHONE
 10. NUMBER OF EMPLOYEES AT THIS LOCATION

 11. BUSINESS DESCRIPTION       .   	
 12. IF THE ADDRESS IS DIFFERENT THAN
    THE LOCATION OF THE FACILITY TO
    WHICH THIS FORM WAS MAILED, INDI-
    CATE THE CORRECT MAILING ADDRESS.
13. IF THIS COMPANY DOES NOT USE, PRODUCE, OR HANDLE ANY
    OF THE CHEMICALS LISTED IN THE INSTRUCTIONS, CHECK THE       NONE!   I
    ADJACENT BOX MARKED "NONE", COMPLETE PARTI AND RETURN.        —'
    NOTE:  READ INSTRUCTIONS ON DEFINITION OF "HANDLE"
    BEFORE COMPLETING                                                ',

14. SIGNATURE OF THE COMPANY OFFICIAL RESPONSIBLE FOR THE COMPLETION OF
    THE FORMS.
    NAME (PRINT).

    TITLE 	 •
.SIGNATURE

 DATE .	
                                     FOR OEP USE ONLY
 PREMISES t.D.
 X-GRIO COORDINATE
 Y-GRID COORDINATE
DHMH 1740A (HEVj



CENSUS TRACT/MOD
RIVER BASIN CODE '
SIC CODE

-------
                         CHEMICAL INVENTORY REPORT FOR STATE TOXIC
                                SUBSTANCES REGISTRY SYSTEM
                                         PART H

                                 CHEMICAL QUESTIONNAIRE

                           (Complete a separate data sheet for each chemical)
                        (COMPANY NAME)
                                          (ADDRESS)
1. CHEMICAL
                                                                 .CAS NO..
2. IN THE SPACE BELOW, DESCRIBE FOR THIS SITE HOW THE CHEMICAL IS (CHECK APPROPRIATE BLOCKS)   LJ USED,
  Q.PRODUCED, D HANDLED, D EXISTS IN STORED WASTE AT- THIS SITE. IF THE CHEMICAL IS A PART OR CON-
  TAMINANT OF ANOTHER MATERIAL OR IS OTHERWISE COMBINED WITH OTHER MATERIALS, INDICATE ITS PERCENT I
  (BY WEIGHT) COMPOSITION IN THE MIXTURE. IF THE CHEMICAL IS STORED IN A TANK, INDICATE THE TANK IDEN-]
  TIFICATION NUMBER.        ...          .                     .   .    .
3.
THE CHEMICAL IS BROUGHT ON SITE.
            METHOD OF
     TRANSPORTATION ONTO SITE
               RAIL
               TRUCK
           II OTHER
                 . % OF TOTAL

                  % OF TOTAL

                  % OF TOTAL
  MAXIMUM AMOUNT ON SITE AT ANY TIME (POUNDS')
    METHOD OF
     STORAGE

STATIONARY STORAGE TANK

DRUM

OTHER
  ANNUAL THROUGHPUT OF THIS CHEMICAL CPOUNDS)_

-------
                           CHEMICAL QUESTIONNAIRE (CONTINUED)
4.
THE CHEMICAL IS PRODUCED AS AN INTERMEDIATE OR FINAL PRODUCT OR HANDLED
AS A BY-PRODUCT OR WASTE ON SITE.
        METHOD OF
     SHIPPING OFF SITE
            RAIL
            TRUCK
        |   [ OTHER
                    % OF TOTAL

                    % OF TOTAL

                    % OF TOTAL
        METHOD OF
         STORAGE.

    STATIONARY STORAGE TANK


    DRUM

[| OTHER
  MAXIMUM AMOUNT ON SITE AT ANY TIME (POUNDS),

  ANNUAL AMOUNT PRODUCED (POUNDS)	

-------
                                PART III: TANK QUESTIONNAIRE
                       (COMPANY NAME)                       (ADDRESS)

I.  TANK DESCRIPTION
   A.  TANK MANUFACTURER
      NAME:
      ADDRESS:
      TANK INSTALLED: YEAR   	NEW	USED
   B. TANK DESIGN     .                _        .
      THIS TANK COMPLIES WITH THE FOLLOWING PROFESSIONAL CODES:

      ASME BOILER AND PRESSURE VESSEL CODE	
      API 620	       UL 58	\	NF?A 53^

      API 650	NFPA 30	UL 142_

      OTHER (SPECIFY)	UNKNOWN	

      OWNER'S TANK I.D. NO.	;	._
      MATERIAL OF CONSTRUCTION: CARBON STEEL	STAINLESS	?1ASTIC_

      CONCRETE	OTHER (SPECIFY)	
      CONSTRUCTION: WELDED    ;   BOLTED	.  JACXETED_	INSULATED,
      VERTICAL	HORIZONTAL	ELEVATED	ONGROUND .      UNDERGROUND,
      (NOTE:  ANY TANK WITH 10% OR MORE OF ITS CAPACITY UNDERGROUND INCLUDING PIPING
              CONSIDER AN UNDERGROUND TANK)
      ROOF: FLOATING	FDXED	OTHER.

      TANK CAPACITY:	(GALLONS)_

-------
II.
                            PART III: TANK QUESTIONNAIRE (CONTINUED)
TANK FUNCTION AND STATUS




A.  TANK FUNCTION
          STORAGE
                                  PROCESSING
                                                              OTHER
      B.   CURRENT TANK STATUS




          TANK IN USE	TEMPORARILY OUT OF SERVICE,
                                                        PERMANENTLY OUT OF SERVICE
          IF TANK OUT OF SERVICE:    EMPTY_
                                         NOT EMPTY
                                                                MATERIAL
                                                                                 GALLONS
          DATE OF LAST USE
ill.    OPERATIONAL DATA




      A.   TEMPERATURE CONDITIONS:




      CRYOGENIC	°F    REFRIGERATED_





      B.   METHOD OF FILLING TANK	
IV.
                                    °F     HEATED
                                                           AMBIENT
      PUMP
            GAS PRESSURE
                                     GRAVITY
OTHER (SPECIFY)
      C.   METHOD OF EMPTYING TANK




      PUMP                 GAS PRESSURE-
                                                   GRAVITY
CORROSION .AND SPILL CONTROL




A.'  CORROSION PROTECTION




    CHEMICAL INHIBITORS	




    STRIKER PLATES
                                    IMPRESSED CURRENT
           ELECTRICAL ISOLATION
                               SACRIFICIAL ANODES
      _OTHER (SPECIFY)_
      3.   LOSS/SPILL CONTROL




          AUTOMATED FILL AND DISCHARGE CONTROL




          LIQUID LEVEL INDICATOR	




          DRAINAGE COLLECTION	CONSERVATION VENTS
                                                 DIKES
                                 TEST WELL
      PRESSURE RELIEF VALVE
                                                        INVENTORY/EMISSION CONTROL
          MOST RECENT TANK TEST DATE
                                             METHOD USED

-------
V.    SECURITY
     CONTROLLED ACCESS:  FENCE_




     CONTRACTUAL SECURITY
  STAFF SECURITY
                                                                      BUILDING
OTHER (SPECIFY)
Vi:   CURRENT PERMITS
     HEALTH DEPARTMENT:  PERMIT NUMBER
     NATURAL RESOURCES:  PERMIT NUMBER
                 _AUTHORIZED USE_




                  AUTHORIZED USE
     WASTE STORAGE




     USE THE SPACE BELOW TO IDENTIFY WASTE CONTAINING A LISTED CHEMICAL THAT IS STORED IN A




     TANK. IF NOT PREVIOUSLY COVERED UNDER PART II, INDICATE HOW THE WASTE IS GENERATED AND




     ITS PERCENT COMPOSITION IF IN A MIXTURE.

-------
                TABLE 1: SELECTED CHEMICAL LIST
                EXEMPT QUANTITY CLASSIFICATION I
       REQUIRES REPORTING OF QUANTITIES GREATER THAN
                      2.2 LBSe (1 KG) PER YEAR
CHEMICAL NAME
2-Acetylaminofluorene
Acrylonitrile
2-Aminoanthraquinone
4-Aminobiphenyl
l-Amino-2-Methylanthraqumone
o-Anisidine
o-Anisidine Hydrochloride
Arsenic
•Arsenic Compounds (Specify)
Asbestos (Friable)
Auramine
Benzene
Benzidine
Benzole Trichloride
Beryllium
Beryllium Compounds (Specify)
Bis(Chloromethyl)Ether
Cadmium
Cadmium Compounds (Specify)
Carbon Tetrachloride
Chloroform
Chloromethyl Methyl Ether
Chromium (fume or dust)
CAS NUMBER
      53-96-3
     107-13-1
     117-79-3
      92-67-1
      82-23-0
      90-04-0
     134-29-2
    7440-38-2

   • 1332-21-4
     492-80-8
      71-43-2
      92-87-5
      98-07-7
    7440-41-7

     542-88-1
    7440-43-9

      56-23-5
      67-66-3
     107-30-2
    7440-47-3

-------
                EXExMPT QUANTITY CLASSIFICATION H

           REQUIRES REPORTING OF QUANTITIES GREATER"
                       THAN 500 LBS. PER' YEAR
 CHEMICAL NAME

 Acetaldehyde

 Acetamide

 Acetone

 Acetonitrile

 Acrolein

 Acrylamide

 Acrylic Acid

 AUyl Chloride

 Aluminum (fume or dust)

 Aluminum Oxide

 4-Aminoazobenzene       .   .

 Ammonia

 Ammonium Nitrate (solution)

 Ammonium Sulfate (solution)

 Aniline

 p-Anisidine

 Antimony (fume or dust)

 Antimony Compounds (Specify)

 Barium

 Barium Compounds (Specify)

Benzamide

Benzyl Chloride

Biphenyl
CAS NUMBER

      75-07-0

      60-35-5

      87-64-1

      75-05-8

     107-02-8

      79-06-1

      79-10-7

    Iff?-OS--1

    7429-90-5

    1344-28-1

      SOr-09-3 .

    7664-41-7

    6484-52-2 "

    7783-20-2

      32-53-3

     104-94-9

    7440-36-0



   7440-39-3



     55-21-0

    100-44-7

     92-52-4

-------
                                APPENDIX D                          '  .

         EXAMPLE CHEMICAL USE VS. EMISSIONS BASED QUESTIONNAIRES



                                Statement                           ;

     The following sample chemical use vs. emissions based question-
naires are examples only and are purely to provide a resource of in-
formation.  They are not to be reused and are not endorsed or recommended
for use, nor do they represent flawless examples.  Each agency should
tailor questionnaires to the specific needs of the area.
                                   D-,1

-------
EXAMPLE 1 -  CHEMICAL  USE QUESTIONNAIRE

-------
                        "Draft Transmittal Latter'
The Air Pollution Control Districts (APCD) in the .                  ,  in
cooperation with  the            Air Resources Board, are conducting a  survey uo
determine  the amounts  used and/or produced of several substances of a?*c±al.
interest.  These  substances are of interest because they may have a significant
effect on  air quality  even through they are used in small quantities.   Under
          . law (Health and Safety Code, section 39660e), you are required to
provide  the information requested in this survey.

We -ealize the time you spend completing a survey is valuable.  Therefore, we
have  made  an  effort to simplify the survey form and have limited tne  ;
information requested.  With this in mind, I  hope that you will promptly
complete and  return the attached form.

Please complete the survey fora using data from the most recent twelve month
pe-iod for which you have information.  Instructions on how  to complete tne
form are on  a separate sheet which is attached.  Some of the suostances ox
1snecial interest" may be contained in products such  as solvents, thinners,
 cleaners,  pestici'des  or fumigants.  If you know  that the product(s) you produce
 or use contain(s) substances listed on the attached  form, please Provide  the
 trade name and the amount produced or used in the  space provided on tne o^..
 side of the survey form. If the  information you  are providing  is  a traae
 secret per Health and Safety Code Section 39660(e),  place a  mark in the
 "Trade Secret" column.  The APCD may later request  that you  provide
 documentation to support any claim of  trade  secret.  In addition,  information
 other than trade secrets 'may be identified  as confidential  in -ccordag«  "1th
 the provisions of Section 91011,  Title 17,  .          Administrative Code.  The
 information which you provide  pursuant  to  this request  m^  be released  (1) to
 the-public upon  request,.except  trade  secrets, whicn is  exemp. .rom disclosure
 or the disclosure  of which is  prohibited  by  law,  and U)  to  the rederal
 Environmental Protection Agency,  which protects trade secrets « P"]*^ ~n
 Section Il4(c) of  the Clean Air Act  and  amendments thereto  (42 USC 7401  et
 seq.) and in  federal  regulations.'   (Section 91010, Title I/ ,        '
 Administrative Code.)  The information,  including traae secret ana ocne.
 confidential  information, may  also  be released to other puolic agenc.es,  whu.c,.
 are  also  required  to  preserve  the protections accorded to traae secrets and
 confidential  information.                                            '

 piease  return the attached survey form within 2 weeks of the date of  receipt.
 If you  have  any  questions regarding this survey, please contact 	,	_•
  Thank  you  for your  cooperation in this survey.
  Sincerely,
  Attachments

-------
                  INSTRUCTIONS TOR COMPLETING THE  SURVEY FORM
General  Comment:   .

    Please read  the  entire instruction  sheet before  starting to complete the
    survey form.   We are looking  for your best estimate of the amount of the
    listed substances your business uses or  produces.  When completing the
    form,  use your best approximation if you do  not  have exact figures.  If you
    think  you will need more  space  than'provided, please feel free to make
    copies of the form before you start.

Procedures:
    The survey  form  is  divided  into  three sections, the company identification
    and heading section,  the  compound  (substance) section, and the trade
    name section.  Procedures, for completing each section are described below.

    Identification Section:
         The form  should come with a name and address label on the upper
         left hand corner.   If your company name or address has been changed,
         please  cross  out the incorrect information and provide the corrected
         name and/or address.  If for  some reason there is no address label,
         please  fill  in  the  information in the space provided."  The information
         on the  top right corner marked "Office Use Only" should not be
         completed.  '        .                       '         .

    Compound Section:

         This section  is divided into  two parts.

         The first part  is for "pure" materials.  Pure material  are anything
         that is 955 or  more of that compound: industrial  grade is considered a
         pure compound.   There are three columns in this part; the first column
         is used if you  directly produce the substance; the second column is
         used if the substance is produced as a by-product of seme process and
         is either sold  or disposed of as a waste; and the third column is used
         if you  purchase the substance from another company.  If you produce  or
         use any of the  49 substances  listed, fill in the appropriate column
         with the  amount produced or used during the most recent 12 month
         period  for which you have records.  Be sure to circle the units,
         pounds  or gallons, that you are using when reporting the annual  amount
         produced  or used.

         The second part of the section is to be used when the substance is
         only a  part of  a mixture or product.  In this  case, fill in the annual
         amount  of the product used or produced in the "amount"  column of this
         part and  then the percentage  of the compound in that product in the
         next column.  Be sure to circle the appropriate units for both the
         amount  used and the percentage, whether.it is  pounds (LB) or gallons
         (GAL) and weight percent (WT) or volume percent (VOL),  respectively.
         Next, place an  "X" in the appropriate column in part 1, to identify  if
         the mixture is  produced or used by your company.   If you produced or
         use several products that contain the same substance, it will be

-------
                     necessary  to make several  copies of  the  fora before starting. < If the
                     compound of interest  is  part of a trade  name product,  please assign  a
                     number to  the product, starting with  1,  and fill in the  appropriate
                     Information for the product in the trade name section  at the end of
                     the survey form.

               Trade Name Section:                                                   :
                     Complete  this section  to  identify the  name and supplier of the
                     product you provided  in  the compound section.

                     Space is  provided to  list the trade name of the product and then the
                     name and  address of the  supplier  for 8 products.  There is a number,  1
                     through 8,  associated  with each trade  name space.  This number is  used
                     in the conpound section  to identify which trade name  goes with which
                     product.                                                          ;

                     At the end  of this section, we have provided space to indicate if  you
                     do not use  any of the  substances  in any form.  Also,  it would be
                     appreciated if you identify a person to contact in case we have any
                     questions about your*response.
           EXAMPLE:

           Company 3 produces 10 toas of  benzyl chloride and has 0.5  ton per yearjof^allyl
           chloride as a  by-product.  This company  also uses 40 thousand gallons of  "super
           solution x* which contains 40%. benzene and  2% .acetaldehyde.   The informations
           provided are .considered to be  "trace secret* by company B.              :
                                                FORrt.TX
COW *HY HAME

5T8EST 	

CITY   	
ZIP
                                                 OFFICE USE QHI.r_
                                                FACUITY10
                                                                     SIC
         SUJSTAHCES
     IXXXXXMXXXXXXXXXXXUMXXNXX
*S5I3 ACETALDEHYDE
»J305 ACXOLEIH
M601 AUYt. CHLORIDE
12103 ARSEHIC tIJIORGAKIC)
12301 ASSE5TOS

*52ll JENZEHE
11002 lEHZYt CHIOR1BE
12103 BERYLLIUM
                            PVEASE CIXCLE THE APPROPRIATED UHIT!!
          AMOUHT PRODUCED          AMOUHT
      DIRECTLY       JY-PRODUCT     IttSB
      XXXXXXXX       XXXXXXJX     '  ftMXUXXXX
      	L3XGAL        IBy'CAL  	y   13/tUL
      	L3XOAI.  	LBXGAC	13/GAt
      	LB/GAL        LBXGAL         L3XGAL
            LS-'CAL
            L3/CAL
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.
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,13/GAt
 L3XGAL
                                                                                IH PXQtHJCT PRODUCES/USE
WT/VQ|
UT/VOi
   TRADE NAME PRODUCT
   xuxxxxxxxxxxxxxxxxxxxx
           SUPPLIER
XXXXXXXXXIXIXXXXXXXXXXXXXXXXXXXXX
           TRADE KAME PRODUCT
           xxxxxxxxxxxxxxxxxxxxxx
                           SUPPLIER
                 xxxxxxxxxxxxvxxxxxxxxxnxxil

                 HAME 	',	.
                 ADDRESS^

-------
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EXAMPLE 2 - EMISSIONS BASED QUESTIONNAIRE

-------
                                APPENDIX D

         EXAMPLE CHEMICAL USE VS. EMISSIONS BASED QUESTIONNAIRES    |



                                Statement

     The following sample chemical use vs. emissions based question-
naires are examples only and are purely to provide a resource of in-
formation.  They are not to be reused and are not endorsed or recommended
for use, nor do they represent flawless examples.  Each agency should
tailor questionnaires to the specific needs of the area.
                                    D-l

-------
EXAMPLE 1 -  CHEMICAL  USE QUESTIONNAIRE

-------
                        "Draft  Transmittal  Lacter1
The Air Pollution Control Districts (APCD)  in the .                  ,  in
cooperation with the            Air Resources Board, are conducting  a  survey  to
determine the amounts used and/or produced  of several substances  of  s?^ia1'
interest.  These substances are of interest because they may have a  significant
effect on'air quality even through they are used in small quantities.  Under
          . law  (Health and Safety Code, section 39660e), you are  required  to
provide  the information requested in this survey.

We realize the  time you spend completing a  survey is valuable.  Therefore,  we
have made an  effort to simplify the survey form and have limited  tne
information requested.  With this in mind,  I hope that you will promptly
complete and  return the attached form.

Please complete the survey fora using data from the most recent twelve month .
t>e-iod for" which you  have information.  Instructions on how to complete  tua
form are on a separate sheet which is attached.  Some of the substances, or
special  interest may  be contained in products such  as solvents, t Dinners,
cleaners, pestici'des  or fumigants.  If you know that the Proauct(s)  you  produce
or  use contain(s)  substances listed on the attached  form, please provide tne
trade name and  the amount produced or used in the space provided  on tne  oaca
side  of  the  survey form.  If the  information you are providing is a trade
secret 'per Health  and Safety Code Section 39660(e), place a mark in the
 "Trade Secret"  column.  The APCD may later request  that you provide
documentation to,support any claim of  trade  secret.  In addition,, information
 other  than'trade secrets may be  identified as confidential  in  accordance with
 the provisions  of  Section  91011,  Title 17,            Administrative Code.  The
 information which  you provide  pursuant to  this  request may  b«r£"8J?aciiLre
 the public upon request,.except  trade  secrets,  which is  exempt .rom disclosure
 or the disclosure  of  which is  prohibited by  law,  and (2)  to  the  rederal  ^
 Environmental Protection Agency,  which protects trade  seerets  as provide*  in
 Section U4(c)  of  the Clean Air  Act and  amendments  thereto  (42 USC  7401 et
 seq.) and in federal  regulations."  (Section 91010, Title  17 ,     _    _
 Administrative Code.)  The information,  including  trade secret ana  otner
 toSideSal information,  may also  be  released  to  other public agencies, whicn
 are also required to  preserve  the protections  accorded to  trade  secrets and
 confidential information.

 Please  return  the attached survey form within 2 weeks  of the date of  receipt.
 If you  have  any questions regarding this survey, please contact  	:	•
 Thank you for your cooperation in this survey.

 Sincerely,


 Attachments

-------
                  INSTRUCTIONS FOR COMPLETING THE SURVEY FORM
General  Comment:   .

    Please read  the  entire  instruction sheet before starting to complete the
    survey form.   We"are  looking  for your best estimate of the amount of the
    listed substances your  business uses or produces.  When completing the
    form,  use  your best approximation if you do not have exact figures.   If you
    think  you  will need more  space than provided, please feel free to make
    copies of  the  form  before you start.

Procedures:
    The survey  form  is  divided  into three sections, the company identification
    and heading section,  the compound  (substance) section, and the trade
    name section.  Procedures, for completing each section are described below.

    Identification Section:
         The form  should come  with  a name and address label on the upper
         left hand corner.   If your company name or address has been changed,
         please cross  out the  Incorrect information and provide the corrected
         name and/or address.   If  for  some reason there is no address label,-
         please fill  in the  information in the space provided.' .The information
         on the top right corner marked "Office Use Only" should not be
   •   '   completed.

    Compound Section:               •                         .       .

         This section  is divided into  two parts.

         The first part is for "pure" materials.  Pure material are anything
         that is 955 or more of that compound: industrial grade is considered a
         pure compound.  There are  three columns in this part; the first column
         is used if you directly produce the substance; the second column is
         used if the substance is  produced as a by-product of seme process and
         is either sold or disposed of as a waste; and the third column is used
         if you purchase the substance from another company.  If you produce or
         use any of the 49 substances  listed, fill in the appropriate column
         with the amount produced  or used during the most recent 12 month
         period for which you  have  records.  Be sure to circle the units,
         pounds or gallons,  that you are using when reporting the annual amount
         produced or used.

         The second part of  the section is to be used when the substance is
         only a part of a mixture  or product.  In this case, fill in the annual
         amount of the product used or produced in-the "amount" column of this
         part and then the percentage  of the compound in that product in the
         next column.   Be sure to  circle the appropriate units for both the
         amount used and the percentage, whether it is pounds (LB) or gallons
         (GAL) and weight percent  (WT) or volume percent (YOL), respectively.
         Next, place an "X"  in the  appropriate column in part 1, to identify if
         the mixture is produced or used by your company.  If you produced or
         use several  products  that contain the same substance, it will be

-------
                     necessary to make several copies of the fora  before starting.   If the
                     compound of Interest 1s part of a trade name  product, please  assign a
                     number to the  product, starting with 1, and fill  In the appropriate
                     Information for the product  1n the trade  name section at  the  end of
                     the survey form.

               Trade Name Section:
                     Complete this  section to  Identify the name  and supplier of  the
                     product you  provided 1n the  compound section.

                     Space 1s provided to 11st the trade name  of the product and then the
                     name and address of the supplier for 8 products.   There is  a number,  1
                     through 8, associated with each trade name  space.   This number ;is used
                     in the compound section to Identify which trade name goes with which
                     product.

                     At the end of  this section,  we have provided space to indicate if you
                     do not use any of the substances in any  form.   Also, it would be
                     appreciated  if you identify  a person to contact in case we  have any
                     questions about your'response.
           EXAMPLE:

           Company B produces  10 tons of benzyl  chloride  and has 0.5 ton  per year of ally!
           chloride as a by-product.  This  company also uses 40-thousand  gallons of "super
           solution x" which contains 40% benzene and 2%  acetaldehyde.  The  informations
           provided are .considered .to be "trace secret" by  company B.
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-------
EXAMPLE 2 - EMISSIONS BASED QUESTIONNAIRE

-------
Dear Sir:

     As  part  of our continuing efforts to improve air quality  in
County,' the           County Health Department Bureau of Air Pollution Control
(Bureau)  is  now engaged in evaluating the effect of chemical  pollutant  air
emissions.    The enclosed forms for reporting of chemical air emissions are a
part  of  that  evaluation.   Your  cooperation in this• effort  is  required,
pursuant to Article XX,  Rules and Regulations of the          'County  Health
Department,  Air Pollution Control,  including sections 201.A, 201.D, 305.A.3,
305.A.5 and 305.A.6.

     Use  the enclosed forms to report your chemical pollutant air  emissions.
Instructions  enclosed' with these forms will assist you in determining   which
chemicals  emitted to the atmosphere should be reported.   To assist  you,  we
have  enclosed  a  listing  of the chemicals reported to the  Bureau  by  your
company as -part of the Chemical Substance Survey.

     If there is insufficient room on page 2 to record all of the emissions to
be reported, please make sufficient additional copies of page 2 before filling
it out.                                                                ;

     Please return the completed forms to the Bureau, at the above address, no
later than                   .  Questions should be referred to
             at

                                      Sincerely yours,
Enclosure

-------
                  Report  of  Chemical  Pollutant  Air Emissions
                                 County  Health Department
                        Bureau  of Air  Pollution  Control

                             General  Instructions
     All  chemical pollutant air emissions are  to  be  reported.    (This  includes
 emissions  from combustion sources.)  Emissions values may  be  based  on  source
 tests,   material   balances,   emission  factors,    vapor    pressure/diffusion
 coefficients,  plant  history or any other acceptable method.    Chemical users
 that have  chemical  processes or combustion sources on site  may have  emissions
 of  chemicals other than  those reported on the survey,  as  those chemicals are
 intermediates in a  process or a by-product of combustion.    Emissions  of these
 chemicals  should be listed also.
                               *
     Fugitive  emissions  (not  vented or in a stack) must  also  be  reported.
 These can  be from open-top blending operations,   degreasing operations,  etc.,
 and  may   be vapors from  volatile organic compounds,  "dusts"  from  inorganic
 pigments,'  etc.   -Emission point parameters should be labeled  "Ambient, ground
 level".
     All  air  emissions  of  chemicl pollutants,  on  'the. attached  lisc  of
pollutants,,  are  to  be  reported.   Emissions of pollutants  for  which  the
Environmental Protection Agency has established ambient air quality  standards
(the.  criteria  pollutants:   suspended'  particulate  matter,,  sulfur  oxides,
nitrogen  .dioxide, •carbon-  monoxide,  ozone and lead) should not be  reported
here.   If  emissions from a process are only the criteria  pollutants,  water
vapor  and/or C02 (Carbon Dioxide),  you do not need to report emissions  from
this process.

     Emissions  are  to  be reported in under  two  conditions:   maximum  (or
uncontrolled)  emissions,  and  normal  (or  controlled)  emissions.   Maximum
emission  races  should be estimated for an uncontrolled  process  at  maximum
operating rates.    In cases where there is little difference between emissions
at maximum and "normal" rates, report "normal" rate data in both columns.

     If  a given chemical is emitted from more than one source,  and only  the
total  emissions  are known,   then under "Description of Emission Source"  list:
all  of  the  sources,   list the chemical and CAS  number  as  indicated,  and
quantify  the emissions under "Normal Emission Rates",   or "Maximum"  Emission
rates.

     The  Bureau   is   including a report of the  chemicals  reported  by  your
company  during  the   Chemical Substance Survey,   and a list of  all  chemical
pollutants to be  reported.   Please use this as a reference when preparing your
emission report.

-------
                  Report of Chemical Pollutant Air Emissions
                                County Health Department
                       Bureau of Air Pollution Control
                                 Instructions


     The  attached  forms are for you to record of your non-cricaria  chemical
pollutant air emissions.

          Address

     1.   In the spaces provided, if necessary, please correct the address for
          any errors on the address label.
     2.   Description of Emission Source

          For  each  emission  source,  name or describe  the  process/outlet::
          paint  booth,  tank  vent,  combustion  stack,  process  vent,  ecc.
          Emissions not attributable  to specific  sources should  be  iaent^xiea
          as  fugitive.   If  air pollution emission  control equipment  is  in
          place  and operating,  please identify  the  type of control equipment
          being used.                    •     .

     3.   Name 'of Air Emission/CAS Number   '.                             :

          Itemize all air emissions from each  source,  and give the appropriate
       •   CAS  (Chemical Abstracts Services) number for  each.    Please  account
          for all chemicals 'reported  on the Chemical  Substance Survey,  even if
          emissions are zero. A  list  of all chemical  pollutants  to be reported
          is also attached.

     4.   Maximum Emission Rates                                         '•

          Report  the  maximum   or  uncontrolled   hourly,    daily and  yearly
          emissions of each named air emission.    Maximum  emissions  should  be
          based  on   the highest operating rates  and  for the highest emission
          rates  that have occurred or might  reasonably  be  expected   to  occur
          for  each respective  time period.

     5.   Normal Emission Rates

          Report   the normal  (controlled)  hourly,  daily and yearly   emissions
           rates  of   each  named  air  emission.    Note:   For either maximum  or
           normal emissions,   a process  operated,  one shift per day,  5 days  per
           week  but   not  holidays,   the  daily emissions might be 8  times  the
           hourly   emissions,   and  the yearly emissions might be 2000 times  the
           hourly   emissions.    For  a  continuous process,  the daily   emissions
           might  be   24  times the hourly  emission,  and the  yearly   emissions
           might  be   8760   times the   hourly  emissions.   These  numbers  are
           dependent  on your operating schedule.  Please take this into  account
           when estimating emissions.

-------
 6.    Emission Point: Parameters

      For  poinc  source emissions, give the emissions  point  temperature
      (degrees F),   total volume of flow,   (cubic feet per minute),  -atack
      gas velocity,   (feet per second),   and the stack height above   grade
      level,  (feet).

      Treat exhaust  vents as  stacks,  but writa "horizontal" if the exhaust
      is    vented horizontally.     For   non-stack/vent  emissions   write
      "fugitive" in  this column.

      Additionally,   in  the   box  in the  lower right hand corner of   the
      Emission  Point  Parameter box,  indicate by the use of one of   the
      following letters how the emissions  estimates were made:

                S    Source "Test

                E    Emissions  Factor — if   the emissions factor is   fron
                                         other then AP-42, please identify
                                         the source
               M
  Material Balance
               0    Other  (describe  on  separate  paper and   return
                    with the forms)

 7.-  Clarifying Data               .   "   '  • •'.   '

     If  there is variation in the  quantity of emissions  from  one time  of
     year to another,  this info'nnation' should be attached  to these forms
     when  they are sent in.   Emissions of greater  than 30%  of the total
    'emitted  or less than 20% of  the total emitted  during  any one  three
     month period would justify such a  clarifying  statement.   Also,  if
     emissions are not continuous  but,  say, only during  the hours of 7 to
     3  Monday through Friday, .  please  so state.   If  there is additional
     data  you  believe would assist in describing   emissions  from  this
     plant, attach that data on a  separate sheet of  paper.
 8.  Return  the
     data to:
completed forms to along with any  clarifying
Questions  concerning  completion  of this form may be  directed  to...

-------

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-------


BUREAU
List


INDUSTRIAL GASES

Acetylene
Anonia
Arsine
Broiine
Chlorine
Oiborane
Fluorine
Hydrogen selenide
Hydrogen sulfide
Methyl acetylene
Hethyl «rcaptan
Nickel carbonyl
Hi trie oxide
Nitrogen dioxide
Ozone
Phosphine
Selsniui hexafluoride
Sulfur dioxide
Sulfur hexafluoride
Sulfur tetrafluoride
Sulfur trioxids
Teiluriut hexafluoride

•-. ' PHARMACEUTICALS ,
Aaphetaiine
2-A*inopyridine
Sacitradn
C.I. basic gresn 1 (brilliant
Cantharidin
Caraachol chloride
Coichicine •
Digitoxin
Oigoxin
Oithiazanine iodide
£«tine dihydrochloride
srgocalci ferol (vitaiin 0)
Ergotaiine tartrate
Fluorouracil
Indciethacin

Hitoiycin C
Husciiol
Quabain ,
Phenylthiourea
Phylloquinone (vitaiin X)
Physostigiine
Physostigiine salicylate
Picrotoxin
Tri s (2-chl oroethyl ) aiine
Valinoiycin
CGUHTY HEALTH DEPARTKEHT

OF AIR POLLUTION CDXTRDL
of Cheakal Substances


CASJUJJBER

74-86-2
7664-41-7
7784-42-1
7726-95-6
7782-50-5
19287-45-7
7782-41-4
7783-07-5
• 7783-06-4
74-99-1
74-93-1
13463-39-3
1.0402-43-9
10102-44-0
10028-15-6
3303-51-2
7783-79-1
7446-09-5
2551-42-4
7783-60-0
7446-11-9
7783-80-4
•

51-64-9
504-29-0
1405-37-4
areen) 633-03-4
56-25-7
51-33-2
64-36-8
71-63-6
20830-35-5
514-73-8
316-42-7
50-14-6
379-79-3
51-21-8
53-36-1

50-07-7
2763-96-4
630-60-4
103-85-5
84-80-0
57-47-6
57-64-7
124-87-8
535-77-1 '
2001-95-8 -
ftCIQS
Acetic acid
Chloroacetic acid
Hydrochloric acid
Hydrogen bro»ide
Hydrogen fluoride (hydrofluoric acid)
Nitric acid
Phosphoric acid
Picric acid
Propionic acid
Sulfuric acid
Thioglycolic acid


"
Acrylonitrila (vinyl cyanide) :
Adiponitrile
Benzyl cyanide
Cyanogen broiide
Cyanogen iodide
Fonaldehyde cyanohydrin
Hydrocyanic acid (hydrogen cyanide)
Isobutyronitrile
Lactonitrile
Halononitrile
Methacrylonitrile
Potassiui cyanide
Potassiui silver cyanide
Propionitrile
Propionitrile, 3-chloro-
Sodiui cyanide

CHEMICAL INTERMEDIATES
Acsialdehyde
Acetic anhydride
Acetone cyanohydrin
Acetone thiose.ticarbazide
Acroiein
Acrylyl chloride
Acrylaiide
Acrylic acid
Allyl alcohol
Allyl chloride
Allyl aiine
Allyl glycidyl ether (A6S)
Ationiu* chloride
Aniline-
Aniline, 2,4,6-tri«ethyl-
Anisidine
ISenzal chloride
Senzenatine, 3-(trifluorotethyl)-
Uenzene, l-(chloroiethyl)-4-nitro-
9enzenesulfonyl chloride
Denzidine
Benzotrichloride
Senzyl chloride



79-n-aH
7647-01 -lH
10035-10-M
7664-39-3H
7697-37-2H
7664-33-2H
£9-39*!BH
79-09-4 IB
7864-93-9H
68-il-iH
1
H
•
107-13-1 IB
11 1-69-3 •
140-29-4 H
506-63-3 H
506-78-5 •
74-90-3 H
! 09-74-0 •
78-97-7 IB
109-77-3 H
126-93-7 H
MWwl
107-12-0 IB
542-76-7 •
143-33-9 M
m
1
75-07-0 I
103-24-7 •
75-86-5 •
1752-30-3 M
107-02-3 H
314-63-6 IB
79-06-i 1
79-10-7 •
107-19-6 1
1 07-05- i •
107-11-9 I
106-92-3 •
12125-02-9 H
62-53-3 M
83-05-1 •
29191-52-4 •
98-37-3 1
98-16-3 •
612-23-7 •
98-09-9 •
92-87-5 •
98-07-7 B
100-44-7 B
1

-------
EXAMPLE 3 - EMISSIONS BASED QUESTIONNAIRE

-------
Dear Sir or Madam:

     The Division of Environmental Management is developing a program to
protect human health  from  the adverse effects  of  toxic  air po.luuants.
A  list  of  toxic  air  pollutants  which may  require  regulatory  c.nc.oi
has  been  formulated;  however,  before  proceeding  any  further  wien
development of an air'toxics control program, we are conducting a survey
to  determine  which  facilities  are  emitting   any .or   .he   -*^  a_,
pollutants  contained  in  Appendix  A  and   to   obtain  otner  essence!
information for-registration purposes.

   '  Attached is a registration form to be filled out by major and minor
facilities emitting air pollutants.  The registration rorm is promulgated

^bcn^er3006 , Regulation  ' '      /Please  . provide   tji guested
information  and  return  the  form to  the  Division  witmn  60  days a.ter
receipt.

     The  registration form  was  designed to  obtain necessary emissions
data-  for  toxic ' air  pollutants  with  a   minimum  or  efrort.    ,he
registration  form  consists  of a General Information Form, a Source  Dc.e
Form with  preceding  instructions,   Appendix   A   entitled^   «oxic   Air-
Pollutants",   and  Appendix  B   entitled   "Division  or   tnvironmenua,
Management  Regional Offices  and Local  Air Programs".

     All  facilities  receiving  a  registration  form must  complete  the
General   Information   Form.    The   official   signing   the   ./"ac-, li uy
certification on   the  General   Information  Form  is   responsible   for
assuring  that   the   registration   form has  been  properly   completed
Facilities  that emit  a  'toxic  air  pollutant listed  "/ppenjlix A  musu
complete  the Source Data  Form.   If a  facility does not emiu any  toxic
sSbstance listed  in Appendix A,  the word "NONE" should  be,entered on the
first  line of  item (3) on  the  Source  Data Form  and  the  registration
materials returned  to the  Division  along  with  the  completed  General

-------
Information  Form.   Emissions  resulting  solely  from  the  combustion  of
wood, coal, natural gas, liquid  petroleum  gas  or unadulterated fuel  oil
need not be  reported".   The instructions for completing  the  Source Data
Form also specify emissions which, for the purpose of this registration,
are  regarded  as   trace  emissions  and  are  not  subject to  the  full
reporting requirements.

     Any information requested on the registration form which a facility
views as confidential  should  be  labeled  with  the word "CONFIDENTIAL"_on
the  form  and  documented  in  a  supplementary  letter,   'Confidential
information will  be treated  in  accordance with                 General
Statute

     If  you  have  any questions  or  need assistance,   please  do_ not
hesitate to  contact us.   Questions  should be directed  to the regional
office responsible for your geographic area as shown in Appendix B or to
the  Air  Toxics  6roupt  located  in                                Your
cooperation will be appVeciated.

                            Sincerely

-------
        Department of
                  Division of Environmental  Management
                 Toxic Air Pollutant Source  Registration
                    Instructions For Source  Data Form
GENERAL

     A Source Data Form must be completed for each emission source at a
facility to include stacks, chimneys, vents, fugitive emission sources
or other sources that emit any substance listed in.Appendix A into^the
atmosphere.  If a facility does not emit any toxic air pollutant  nstea
in Appendix A, then, after filling out the General Information Form tne
word "NONE" should be entered on the first line of item U) on tne
Source Data Form and the materials returned to the Division.
     Source emissions resulting solely from the combustion of wooc,
coal, natural gas, liquid petroleum gas, or unadulterated rue! oil do
not need to be reported in this registration.  Facilities emitting air^
pollutants in Appendix-A with a maximum source emission rate(s/ equa ,  to
or less than the emission rate(s) specified in Appendix A ror trie    ^
aoDlicable toxic air pollutant should complete only items \i), ^2;j3_\^
and (4) and enter the word "TRACE" in the applicable column(s; ror item
(5).  The emission rates in Appendix A are expressed in "Maximum
Emission Rate, P.ounds/Hour" and "Maximum Emission Rate, Pounds/la

     Maximum emissions for the 15 minu.te period should be reported only
for those toxic air pollutants in Appendix A having a corresponding •
value under the column "Maximum Emission Rate, Pounds/15 Minutes  .   I.
the actual maximum!15 minute emission rate is equal to or less tnan  the
15 minute emission rate in Appendix A, -then the emission is considered
to be a trace emission.                              „_„„„_„   .,,',
     Emissions of toxic air pollutants identified as "TRACE  will_be
considered to have an emission rate equal to the  applicable emission
rate(s) in Appendix -A.


SOURCE  DATA  FORM  ITEMS

Item  (1) Source Description.                 '              .       ,
     Provide a description of  the source to which the  remainder  or_tne
      information  on the Source Data  Form applies.   Give  the type  of
     source  (e.g.,  incinerator, storage tank, wastewater  lagoon,
     manufacturing  building, spray booth, etc.) and  its  designation
      (e.g..  Unit  1, Bldg. A.,  etc. within the  facility.   Identical
     source  descriptions with  closely related  emission  characteristics
'  -   may be  combined.  The total  number of  sources,  including  the
      representative source, should be specified in  the  Source
      Description,  e.a., Spray  Booths  (6).   All entries  on  the  Source
      Data  Form  should be completed for  the  representative  source.  The
     Maximum Emissions rates,  however, must  be the-sum of  the  emission
      rates for  all  of the  subject sources..

 Item  (2) Emission Type
      Enter the  emission type using the  codes  at the bottom of_the Source
 Data  Form.   For  the purposes of  this  registration,  the following
 definitions  apply:

-------
    A.
     Unobstructed Vertical  Stack  or  Chimney  -  Any  point  in  a  source
     designed  to emit  solids,  liquids  or  cases  into  the  air,
     including  a pipe  or  a  duct but  not  includ:r,n  flares  and  that
     is  constructed  in a  vertical  direction  a:vd  is vo'id  of
     restrictive obstructions, e..g.,  rain caps.
     Obstructed or Nonverticai Stick  or  Chimney  -  Any  point in  a
     source  designed to emit  solids,  liquids or  g;i?es  into  the^ir,
     including  a pipe  or  a  duct but  not  inuludino  flares  anc  that
     is  either  constructed  in  a nonvertical  direction  or has  a
     restrictive obstruction,  e.g.,  rsin  caps.
     Other Point Source - An  identifiable piece  of equipment  that
     is  used as a complete  unit to accomplish  a  specific purpose or
     produce a  specific product which  results  in en  emission^
     through a  vent  or functionally  equivalent opening excluding
     stacks  or  chimneys.  Describe the particular  point  source.
     Fugitive  Emissions - Those emissions which  could  net
     reasonably pass through  a stack,  chimney,  vent  or other
     functionally equivalent  opening.   This  includes por.ds  or
     lagoons which are used as reservoirs for  cooling  water.
     wastewater or'other  liquid mixtures.  Routine leaks entering
     the atmosphere  from  pipes, valves,  tanks,  condensers or  other
     equipment  are also considered fugit'jre  emissions  and must  be
     reported.
     Other - All other emission types  net identified by A-,  3, C or
     0.   Describe the  particular  emission type falling
     category.
                                                            within  this
Item (3)  Chemical  Emitted  To  Air
     List all  the  chemicals  in  Appendi*  A that,, for the subject source
  •   description,  are emitted into' the'atmosphere.   For the toxic  air
     pollutants  listed as  a-rnetal  and ..its'compounds, e..g.. ,• arsenic and
     compounds,  each individual  compound emitted must be identified^and
     addressed individually  on  the Source Data Form.  Uss  additional
     Source Data Forms as  necessary.

Item (4)  CAS Number                                   ^         ^
     Enter the unique number  assigned to the chemical listed in Item (3
     by the Chemical-Abstract Service (CAS).  Appendix A lists the CAS
     number for most of the  subject chemicals.  CAS numbers may also be
     obtained from Material  Safety Data  Sheets.  If you are unable to
     locate a CAS  number,  contact  the Air Toxics G*-oup at
Item (5)  Maximum Emissions
     List the maximum emission rates
                                for
the
                                        suDject emission source in
pounds per hour and in pounds per 15 .minutes.  The maximum emission
rate in pounds per hour is a normal  maximum rate, e.g., the hourly
rate of the maximum 24 hour production.  The maximum emission rate ^
in pounds per 15 minutes, however, includes startups, shutdowns and
malfunctions.  Only those chemical emissions having ar. entry under
the column "Maximum Emission Rate, Pounds/15 Minutes'1 in Appendix A
     should be listed under the 15 minute time period.
     noted that when calculating the maximum emissions
                                                   It should be
                                                   rrom storage
tanks, both working losses and breathing losses must be considered.
Working losses will be greatest during refilling of tanks when
vapor laden air is displaced.  Calculations for working loss

-------
     il^let?er(sfo?.the calculation method using-the codas at
     the  bottom  of-  the Source Data  Form which best describes the
     methcd(s) used to determine the emission rates in item (5).
Item (7)  Stack or Vent  Diameter                       •
     Give the  inside  exit  diameter  of  the  stacsc  or vent  in
     nearest tenth of a foot.
feet to  the
                            m  ieet above  the  ground  level  of  the
     emission outlet.   For a fugitive  emission,  give  the  height  rrcm
     which the emissions  originate.

     Ente?theVeil?velocity in feet per second  of the emission  at  the
     maximum operating rate.

U6m ^"ter'the IxlfSperature In degrees Fahrenheit of the .1«1on
     outlet at the maximum operating rate.

-------
                 Department  of
                           Division  of Environmental  Management
                          Toxic  Air  Pollutant  Source  Registration
                                 General  Information  Form
FACILITY INFORMATION
1.    Facility Name
2.    Facility Address
                                Street Numoer and Name
             County
                                      City
ZID Coae
3.   Mailing Address (if different than facility address)
                       Street Number and Name or P.O.  Box
                                                            Zip Code
             City                   State

4.    Existing Air Permit Mumber(s)

5.    Primary Four Digit Standard Industrial  Classification Number
6.   Are there any land surfaces within three miles'of your location which
     are higher than your lowest stack or vented emission point? 	

7.   'Does your facility have any fuel burning sources? '__	

8.   Facility Contact Person 	:	

     Title
                                              Telephone Number(   )
                                                             Area Code
FACILITY CERTIFICATION
     I certify that the information contained in this registration is true,
complete and correct to the best of my knowledge.
       Authorized Signature
                                            'itle
             Date
REGISTRATION SUBMITTAL
     This registration form should be completed and transmitted within
60 days after receipt to:

                    Division of Environmental Management
                    Air Quality Section

-------
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-------
                                APPENDIX E

                    EXAMPLE PERMIT TYPE QUESTIONNAIRES



                                Statement

     The following sample permit type questionnaires are examples only
and are purely to provide a resource of information.  They are not to  be
reused and are not endorsed or recommended for use, nor do they represent
flawless examples.  Each agency should tailor questionnaires to the
specific needs of the area.
                                   E-l

-------
EXAMPLE 1 - PERMIT QUESTIONNAIRE

-------
F AIR
OFFICE
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19 FACILITY IIAME (IF DIFFERENT FROM OWNER/FIRM) I
9 NAME OF AUTHORIZED AGENT 10 TELEPHONE
1. NAME OF OWNER /FIRM
I
|
I
20. FACILITY LOCATION (NUMBER AND STREET ADDRtSs]
II NUMQER INO STREET ADDRESS
£., NUMUtH AND STREET ADDRESS
a.
C 
-UWNtK ULASSIHCATIOU cfl'T'TC
A Q COMMERCIAL C Q UTILITY F. Q MUNICIPAL
B Q INDUSTRIAL O.Q FEDERAL 0. Q EOUC. INST
28 CERTIFICATE TO OPERATE
A.QNEW SOURCE Cf~l "(STING
an EDIFICATION L'SOIJ"«
2
27. PERMIT TO CONS)
AQ NEW SOURCE
B Q MODIFICATION
a
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18 SIGNATURE OF OWNERS REPRESENTATIVE OR AGENl
APPLYING FOfl A PERMIT TO CONSTRUCT
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-------
EXAMPLE 2 - PERMIT QUESTIONNAIRE

-------
                                           STATE OF

                                 DEPARTMENT OF ENVIRONMENTAL PROTECTION

                                    DIVISION OF ENVIRONMENTAL QUALITY


                                  TOXIC CATASTROPHE PREVgMTinm ACT
  EFFECTIVE DATE:    January 8, 1986
  EXTRAORDINARILY HAZARDOUS SUBSTANCE (EHSl
               manufactV,red' *ored or. caPable of faeing produced in sufficient quantities that its relea
into the environment would produce a significant likelihood that persons exposed will suffer acute   ""
effects resulting in death or permanent disability.
                                                                                               se
QUANTITY
> 2000 Ibs.
> 2000 Ibs.
> 500 Ibs.
> 500 Ibs.
> 500 Ibs.
> 500 Ibs.
> 500 Ibs.
> 100 Ibs.


> 100 Ibs.
> 100 Ibs.

> 100 Ibs.


COMPOUND | SYNONYMS
Hydrogen chloride
Allyl chloride
Hydrogen cyanide
Hydrogen fluoride
Hydrogen Sulfide
Chlorine
Phosphorus Trichloride
Phosgene


Bromine
Methyl isocyanate

Toluene-2.4-Diisocyanate


Hydrochloric acid
3-chloropropene
Hydrocyanic acid
Hydrofluoric acid
	
_ _
— —
Carfaonyl Chloride
Carbofiic acid dichloride
Chloroforrnyl chloride

Metnylcarbylamine
Methyl ester isocyanic acid
2,4-Oiisocyanatotoluene
2.4-Toiylenediisocyanate
2.4-Qiisocyanato-l-Methyl Benzene
FORMULA
HCi
C!CH_CH=CH,
2 2
HCN
HF
H-S
4,
Cl.
2
PCI.
3
. coci2



Br2
CH3 NCO

Cg Hs N2 02


     MANAGEMENT PROGRAM


A Risk Management Program, as defined in Section 3i of the Toxic Catastrophe Prevention Act. is as follows:




                                 * **?** ^^^ ^-'— «nts for SSSlSSJJpSS"
         m^' PreVentT maintenf nce Programs, requirements for operator training
         and accident investigation procedures, requirements for risk assessment for soecific
                 r  x«rr     ri-'              * emergencvon» pe,g
                or external aud.t procedures to ensure programs are being executed as planned.

-------
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-------
                                                                                                     Page
SECTION F
Make additional copies of this page or provide attachments if necessary.

1.  Does the facility have an existing Risk Management Program (RMP) as defined in Section 3i of the Toxic
    Catastrophe Prevention Act.  (See attached table for definition of RMP.)     rn yes   D No
                                           >^          . "•

2.  If the facility has an existing RMP, identify the major items included'in the plan.
3.  Identify any risk reduction efforts and safety measures employed by the facility to minimize the risks of
    an accidental release of an EHS from the equipment listed in Section E3.
4.  Identify the position titles and expertise of the persons involved with the development of the Risk Managemen-
    Program and the identification of risks and hazards associated with the handling of the EHS,
POSITION TITLE




EXPSHTISS
AFFILIATION
• ' I

. ._




5.  Provide a description of the area surrounding the facility, including location of other companies, residential
    areas and major highways.  Indicate proximity to schools, hospitals, nursing homes and public water supplies
    if tocated within a two mile radius.
    Provide a USGS Topographic Map of the area indicating the location of the subject facility.
SECTION G

INSURANCE CARRIERS - Identify those insurance carriers underwriting the facility's environmental liability and worksj
compensation insurance policies.
NAME



ADDRESS


'
TYPE OF
POLICY



AMOUNT
OF
INSURANCE

LIMITATIONS OR
EXCLUSIONS

|
!

-------
EXAMPLE 3 - PERMIT (REGISTRATION)  QUESTIONNAIRE

-------
                                     DEPARTMENT
OF ENVIRONMENTAL PROTECTION
                                           BUREAU OF AIR POLLUTION CONTROL
                                   INSTRUCTIONS FOR COMPLETING REGISTRATION FOR
                        STORAGE, TRANSFER AND USE OF TOXIC VOLATILE ORGANIC SUBSTANCES

                                                 FORMS VEM- 029 & VEM- 030
          .  Administrative Code, Title 7. Chapter 27, Subchapter 17, Section  17.3(a). requires that no person snail cause, suffar.
 allow or permit any toxic volatile organic substance listed in Table 1 (see Subchapter 17) to be emitted from any source operation,
 storage tank or transfer operation into the outdoor atmosphere unless such equipment and operation is registered with the Depart-
 ment of Environmental Protection  by June 17, 1979.

 General

 Submit one VEM-Q29 registration for each stack or equivalent stack. (See following definition.)
 Submit one VEM-030 for each source operation venting to the stack.  One permit-certificate number will be issued  for each stack.
              Equivalent Stack: If two (2) or more stacks are utilized to vent one (1) or more source operations, the
              stack venting system will be referred to as an equivalent stack.  References to stacks throughout these
              instructions shall mean stacks or equivalent stacks. References  to sources shall  mean source oaerations.

 FORM VEM-029

  ••e. A 1. Full  Business Name - Refers to the name of the corporation, company, association, society, firm, partnership,
                             individual or political  subdivision.of the state.

 Sec. 8 • Stack' Data Information                                                         .                   -
 A separate form VEM-029 must be  submitted for aach stack, vent, chimney or opening.
 1    Company Designation • Enter name or number by which the company identifies stack, chimney, vent or opening.
 2    Certificate Numbers (if any) • List certificate numbers, if any, assigned to this stack.
 3    Number of Sources Connected  to this Stack
     a. For a single stack venting one or more sources indicate number of sources. Proceed to  Item Number (4), Section 3.
     b.  For multiple stacks venting  one or more sources include a simple diagram showing sources, control apparatus and stacks.
        Include information required in Items 4 to 9 of Section 8 for each stack. Indicate number of stacks in Section 3, item 3b.
 4    Distance to the Nearest Property Line (ft.)-  No instructions required.
 5    Stack Diameter (in.)- Insert stack diameter in inches for circular stacks. Insert cross sectional dimensions
     for square or rectangular stacks.  (Equivalent diameter is acceptable /or square or rectangular stacks.)
 6    Discharge  Height Above Ground (ft.) - Indicate trie vertical distance from .ground level to the stack exit point in fast.
 7    Exit Temperature of Stack Gases (°F) - No instructions  required.
 3    Volume of Gas Discharged at Stack Conditions (A.C.F.M.) -  Give the volume rate of gas discharged from the stack in actual
    cubic feet per minute (ACFM) at stack conditions.
 9   Discharge  Direction (Horizontal. Down or UP) •  if at an  angle choose nearest direction.  Use horizontal for stacks with  rain caps.
    Signature:  The signature must be that of an authorized officer or employee of the operator or owner whose business name
               appears in section A  1.

 «. C • No instructions required.

 FORM VEM-030 - Complete a VEM-030  Emission Source Data form for each source vented to the stack, conduit, flue, duct, vent
or similar opening.

-------
Sec D -Source Information
,   Source Description. Include a brief description of the source operation from which ,ir contaminants are emi.ied. Include
    and model number of equipment if applicable.
2   Operating Schedule - Fractions of an hour of operation must be registered in hrS/day to the nearest hour.  Important - Indij
    the anticipated start-up date.	
3   % Annual Throughout (by ouarterL- No instructions required.
4   Discharge Volume & Temperature • No instructions required.

See. £ • Control Apparatus
    Description - Include a brief description of the air pollution control system.  Please note that a product recovery unit is
    control device.
    Indicate the initial cost of each control apparatus and related ductwork.
    Under annual operating cost, include the cost to maintain and operate each control apparatus and related ductwork.
    Under number of sources connected, indicate for each control the number of sources connected.  (A control device is  not
    Important:  Attach a description of the air pollution control system.  Attachment must hp included to provide details, '
    control apparatus. This description must include the basic methods applied to remove air contaminant* as well as we
             Data and calculations used in the sizing and selection of the control aoparatus.
             If the control apparatus is a standard commercia! piece of equipment, specify the manufacturer, modal. :izs. :YCS|
             and capacity of the apparatus. (Sales brochures would be helpful.)
             If the control apparatus is other than standard equipment, provide a sketch of the control apparatus. Provide the |
             calculations as used to determine the control efficiency.
             Describe the means of disposal of any air contaminants which are collected by the control apparatus.
             Show any bypasses of the control apparatus and specify when such" bypasses are to be used and under what condiJ
             Describe the procedure to be used for preventing losses of air contaminants to the open air whan repairing, servicij
             cleaning, reactivating, or otherwise maintaining and operating the unit.
             Indicate the temperature of gases entering into and leaving the control device-
             Indicate the direction of gas flow through the device and the pressure drop across the device.

 Additional Data Needed For Specific Control Devices
 Scrubber
 Type of Scrubber i.e.. venturi, bubble plate
 Gas Flow Rate Before the Scrubber
 Liquid Flow Hate in gal/min
 Scrubbing Liquid used  .
 Chemical Additives Used (if any! and smounts
 Scrubbing Liquid, once through or recirculated
 Sketch of Device
 Pressure Drop across Scrubber
 Demister type and dimensions

 Note:  For packed scrubber indicate type of
        packing and dimensions of packed bed.

 Cyclones

 Wet or Dry Cyclones
 Size Distribution of Contaminant
 Density of Contaminant
 Cyclone Inlet Temperature  (°FJ
 Dimensions of Cyclone
Electrostatic Preeioitators
Evidence that contaminant is liquid or solid (not vaoor).
contaminants heated or cooled between source and pracipj
Type of Unit i.e., 1  or 2 stage; tube or plate
Method of Cleaning, i.e., raoping, gravity, wash off
Capacity (CFM)
% Moisture in Gas Stream
Temperature of Inlet Stream (°F)
Collecting Surface,  ft2
Apparent Migration Velocity (Precipitation rsta!
Corona Power
Resistivity of Particles

Sag House

Number and size  of bags
Total cloth filtering area
Maximum  capacity in cubic feet/minute
Type of bag fabric
Bag Fabric Weight if available
Weave and Finish of bags,  if available
Air/Cloth ratio
Method of Cleaning

-------
 Filter Pads or Kilter Banks •
 Type of Filters
 Dimensions of Filter Sank

 Adsorption

 Adsorbent
 Operating Pressures
 Dimensions of Sed
 Cubic Feet/Minute through bed
 Method of Measuring Activity
 Method of Schedule  of Reactivation (if applicable)
 Method of Disposal of Desorbate

 Condensers

Type of condenser
Eotrance and exit temperaiures of gas stream
Type of cooling medium
Fiow in gals/min of cooling liquid
Area of cooling surface

SK. F - Air Contaminants From Source

                    EmSsi°nS "bs/hf>
                                                                 •3-
                                                                  Absorption

                                                                  Type, packed, sieve plate, bubble plate, or other
                                                                  Dimensions
                                                                  Liquid used
                                                                  Amount of liquid used in gai/min
                                                                  Gas Plow Rate through unit in standard cubic fset/minute
                                                                  How is rich liquid disposed of?  Stripping tower, neutralization
                                                                  other?
                                                                  Number of transfer units (NOG); Ht. of transfer units (HOGi
                                                                  Identify surfactants

                                                                  Compression.  Refrigeration

                                                                  Equilibrium temperature of condenser
                                                                  Composition of feed vapor
                                                                  Composition of recovered liquid and/or vapor and
                                                                 quantity of each
                                                                 Number of equilibrium stages
                                              ?Pr H""r- Li« each air contaminant (chemical name) which evolves from rne oper=-
             .....                                 ' •—           •  -*•••-—•••••w.iv iwns.niwai Home/ wiuun svoives Trom cne oner3-
         . and » d,scharged ,nto the open air through the stack, chimney, etc. The amissions should be axoressed in oounds oe' ho-r
      General terms sucn as particulates, hydrocarbons, suifates, ate. will not be acceptable.  However, "oarticulates" will be an ac-Y-
      3OI8 term  (Of indirect hear exchanaer anrf inrinprarcic amiW.A*«   ^ u           -                '                      «*—- -^«.
      *.-.„,.:„„ -,.„,.     -   -    -   *' ?"r mc!nerator emissions.  Other terms which adequately describe the emissions from manu-
      facturing processes, i.e.  C-, to Cs HC. NOX. alumina-silica, ssnd, stone will be acceptable.  •
              Note: • Terms such as "none", "nil", "trace", "negligible", etc. will' no.t be acceptable However.  "!ess than	 pounds!
                     per hour  or similar statement may be accepted.              '          '   .    '   '         '                  I
      Under the co.umn marked "How Determined" insert the proper code(si as listed below. Attach any test results or calculations.
      Contaminant emissions determined by:
      1.  Stack test or.other emission measurements                 4.  Estimate
      2.  Material balance                                         e  r
      i   — ,  ,   .     .    __                                     3-  Calculation using special~emission factors chat diffa-
      3.  Calculation using EPA emission factors from AP-42
          e  glssrnace.
 See. G-A  Manufacturing & Material Handling
                                                                      -
                         "3"             " **"* °PS™°n -""'* ''* * ™™*™cinq operation and also fuei burni
                                                                                                                ed for -he
                                                                                                            ng
                                     *•
                                  -**»
                                                             mo,,
                                                                                                              ,lqw di,onm
 2   Total materials processed - No instructions required.
 3   Raw Materials, % 8y W.inhr •' List ,11 raw materiais that are to be charged into the source. (Excluding air and water)
 Sac. G-B • Fuel Burning Equipment
                                        means the rate at wh;ch :
            is introduced into the fuel burning equipment.

                             'Direct Heat Exchanger" means equipment in which heat from the combustion of fuel is transferred to
                          I so that the latter ,s contacted by the products of combustion and may contribute to the total effluent
                 ^exchanger  means equipment in which heat from the combustion of fuel is transferred by conduction throuah a heat I
              , matanal to a substance bemg heated so that the latter is not contacted by and adds nothing to the product of combustio
3   Type primary Fuel-Secondary F,,el. .ndicate the type of fuel used and, if applicable, the secondary fuel type used
      l-uel  means solid, l.quid or gaseous materials used to producs useful heat by burning.
4   Firing Method- Indicate the method of firing, for the primary and secondary fuel, as out.ined on the following page:

-------
Solid Fuel
Wet Bottom
Dry Bottom
Stoker (specify)
C ff. c a/ o..i«... :-
Firing
Fluidized Bed
Cyclone
Other (Specify)
Liouid
Rotary Cup
Steam Atomization
Air Atomization
• 4 -
Fuel Firing
Mechanical Atomization
Other (Specify)
Gaseous Fuel Firing
Forced Draft
Otner (Specify)
   7   Amount Burned Per Year - No instructions required.
   Sec. G-C • Incineration

   1    Tvoe of Unit - Name the type of incineration unit by using the. following designations and include ths maka and modal
       number if applicable:
       Single Chamber Incinerator                                  Pathological Incinerator
       Single Chamber Incinerator with controlled air                Sludge Incinerator
       Single Chamber Incinerator with auxiliary  fuel                 Flare-(visible flame or hidden flame)
       Multiple Chamber Incinerator                               Other Incinerator (specify)
       Multiple Chamber Incinerator with controlled air
       Multiple Chamber Incinerator with auxiliary  fuel

       Include attachments indicating all the control methods and the amounts of air contaminants with ajid without controi devic
      for the following:
                                                                                         HC!
                                                                                        Total Hydrocarbons (nan methanj
                                                                                        NOX, CO, S02
                                                                                        Pb, Hg. Cd, As, Al, Fe, Sn, C.-
 2
 3
  Paniculates (corrected to 12% C02 excluding the auxiliary fuel contribution
  Smoke (indicating Ringelman Number)
  Unburned Waste and Ash
  Odors
  Submit a sketch of the incinerator design indicating the following:
  Information on burner controls, setting and cycles to be usad.
  All burners, primary and secondary, and their locations.
  The BTU/hr rating of each burner.
  Method of refuse feed, (i.e., manual, conveyor, etc.)
  Indicate overfire or underfire air if applicable and show the location of entrance ports.      .
  Include minimum operating temperatures and retention  time in all incinerator chambers. Show locations of temp, sensors.
  Constituents of Waste(s) - Specify the composition of the wastes to be incinerated.
 Waste Code - Check the type of waste(s) that will be incinerated using the codes expressed in   AC 7:27-11.
 Sec. G-0 - Storage Facility

 1   Tank Contents • Specify the chemical composition of the contents of the tank or bin. Designations such as gasoline, No. 2
     fuel oil, etc. will be acceptable.

 2   Tank or Bin Type - Indicate the height or length of tank or bin in rest.  (Length if horizontal, Height if vertical)  Denote :r.e
     type of tank or bin utilizing one of the followina:
             Fixed Roof
             Fixed Roof, Internal Floating Roof
             Fixed Roof. Conservation Vent
             Variable vapor space
             Pressurized
             Open Top Tank
4
5
6
7
8
                                               For a Floating Roof indicate whether there is a single or double seal
                                               Floating Roof
                                               Floating Hoof single deck pan
                                               Floating Roof double deck pan
                                               Floating Roof single deck pontoon
                                               Floating Roof double deck pontoon
 Caoac'ty ' lnsert the capacity of tank or bin in thousands of gallons for liquid storage and thousands of cubic feet for gaseous
 or solid storage. Check on application the units used.
 Equivalent or Actual Diameter - Indicate the diameter of the tank or bin in feet.  For tanks which are not spherical or
 cylindrical, submit dimensions of tank or bin in feet. (Equivalent diameter is acceptable.)
 Vaoor Pressure - No instructions required.
 Filtinq Rate • No instructions required.
 Method of Fill - No instructions required.
Color of Tank - No instructions required.
 Insulated Tank  - No instructions required.

-------
             TO:
                                  STATE DEPARTMENT
                                                                                                                Slas
                                                                        OP ENVIRONMENTAL PROTECTION
                                             BUREAU OF AIR POLLUTION CONTROL
                                                      REGISTRATION FOR
                                              STORAGE. TRANSFER AND USE OF
                                           TOXIC VOLATILE ORGANIC SUBSTANCES
                                         Read Instructions Before Completing Registmion
             1. Full Business Name
             2. Mailing Address
            3. Division and/or Plant Name
            4. Plant Location _ .
            5. Location of equipment on premises (SIdg., Dept.. Area, arc.)
            5. Nature of Business
            7. Plant Contact	
                                Nim« (Print or Typ«)
                                                                       (Mun.c.oality)"
                                                                         Titie
              STACK INFORMATION (EQUIVALENT STACK INFORMATION)
            I. Company Designation of Stack(s)
            !. Certificate Numbers (if any)	1
            .  a.   Number of Sources Venting to this Stack	
              b.   Number of Stacks Venting Source Operation(s)
            .  Distance to the nearest Property Line (ft.)	
              Stack Diameter (inches)
                                                                                                 (County}
                                                                                                     Talephana No.
      (Complete a separate VEM-030 for each source.
             Discharge Height Above Ground (ft.)_
             Exit Temperature of Stack Gases (°F)
             Volume of Gas Discharged at Stack Conditions (A.C.F.M
             Discharge Direction          CD  Horizontal          Qup
             CjDown
The information supplied on Registrations VEM-029 and VEM-030 including
true and correct.
the data in supplements, fs to the best of my knowledge
                           Nam« (Print or Tvo«>
                                                                                             Till.
                                            FOR ASSISTANCE CALL -

-------
SECTION C
DIAGRAM INSTRUCTIONS- A diagram must be included showing the configuration of ail
stacks, control apparatus and sources related to this application.  NOTE: In cases of multiple
stacks, include the following information for each stack:  (1) distance to nearest property
line, (2) stack diameters, (3) stack height above ground, (4) exit temperature (°F) of stack
gases, (s, volume rate OT gases iAIHVIJ oiScnarged at slac* conditions, (67 u.b location and-
type of control apparatus,  (7} direction of flows, and (8) maximum stack emissions
                                                   Disaram

-------
                             STATE DEPARTMENT
                                                                  OF ENVIRONMENTAL PROTECTION
                                    ,*: BUREAU OF AIR POLLUTION CONTROL


                                                REGISTRATION FOR

                                         trroR-ACc, ruAAiii-cri ANU Uih.UK

                                      TOXIC VOLATILE ORGANIC SUBSTANCES


                       ._            Source Emissions And Source Data Form

                       (Complete Ms form for each source and suomir wich Registra{,-on  Fom VSM,Q2g)
       i

       \ SOURCE INFORMATION



        1. Source Description.




        2. Operating Schedule
o
LU
C/3
        3. % Annual Production Throughput

          8y Quarter

        4. Volume Of Gas Discharged

          From This Source (ACFM)
      i               ' '    - ii    .1        , ,_.


      j CONTROL APPARATUS ON SOURCE
 O   !
          Primary
 O
 ui
 in
       Secondary



       Tertiary	i
                                                        Houn/Yajr
                                                                                    Ooeration Starting Oata
                                             Jan .-Mar.
                                                         Aor.-June      Juiv-Saot.


                                                          Source Discharge

                                                          Temperature (°F) 	
                                                       C^oital

                                                    Cast (OoIUrjl
                                                                         Annual Coeraring

                                                                          Cost (OollariJ
                                                                                                      Cc
                                 Sourc

                                nnecracl
      AIR CONTAMINANTS FROM SOURCE


               CONTAMINANT NAME
o
ULJ
                                                  Emission? w/o

                                                Control (lbi./hr.)
                                                ANO
 Smiasionx witn

Control  (Ibj./nr.)
                                                                                                   How
                                                                                                         AN 01
                               Full Business Name



                               Company Designation of Stack(s)

-------
til
en
       A. MANUFACTURING AND MATERIALS HANDLING
       1. Process Description  .  	
       2. Total Amount
         Materials Processed
       3. Raw Materials
                            O  Batch
                                Continuous.
                                                       .lb/batch,_
                                 . hr/batch
                                          % By Wt.
                                                               .Ib/hr
                                                                  Raw Materials
                                                                                                   3y Wt.
      3. FUEL BURNING EQUIPMENT
      1. Gross Heat Input (10S3TU/HR) _
      2. Type Heat Exchange
                                   CU  Direct
                                   PRIMARY FUEL
      3. a. Type of Fuel:	
        b. Heating Value (Stu/Ib.J:
      4. Method of Firing: 	
      5, % Sulfur in Fuei (Dry):
                                                               CU Indirect          O  Internal Combustic
                                                                              SECONDARY FUEL
      6. % Ash Content of Fuel (Dry):
      7. Amount Surned/Yr	
                    Units:    Solid Fuel (Tons)
                                                        Licjuid Fuei (1Q-3 Gal.)
     C. INCINERATION
     1. Type of Unit	
     2.. Constituents of Waste(s)'
     3. Waste Code
4. Amount Burned (Ibs./hr.J
———————____
D. STORAGE FACILITY
1. Tank Contents
2. Type of Tank or Bin
3. Capacity	
                                                                                       Gasaous Fuel {1C6Ft.
                                                       Q3       Q4      CIS
                                                       Type of Auxii. Fuef (if any).
                                    . (103Ft.3)
                                     .(103GaU
                                             a
                                             a
Equivalent or Actual Diameter (Ft.)
                   THE REMAINING QUESTIONS ARE TO BE ANSWERED ONLY FOR LIQUID STORAGE
    4. Vapor Pressure at 700F(PS,A)	.	__   Storage Temp. If Not Ambient (°F) 	
    5. FiHing Rate (Ga./Min) 	;	   Anmja( Tnroughput (1Q3(3a(/Yr)
    6. Method of Fin            O  Top       Q Bottom         d Submerged
    7. Color of Tank             CU  White      Q Other
    8. Insulation Data for Insulated Tanks (Volatile Organic Substances)
                                                                              I—!  Other (Explain Salowj
                                                          Exposed to Suns Rays   QYes    CJNo
                              Thickness (Inches)
                                                               . Thermal Conductivity
                                           For Department Use Only
                                          rrn  rm   rm

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                                APPENDIX F

                      EXAMPLE GENERAL QUESTIONNAIRES



                                Statement

     This example Is a special  general questionnaire used for emeraency
preparedness type programs.  The format is typical  of a general  ques-
tionnaire and the example shown here is for this reason.  Although this
type questionnaire can provide  valuable non-emergency information it is
not usually used in air toxics  programs.
                                  F-l

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         AIR TOXICS  EMERGENCY  PREPAREDNESS QUESTIONNAIRE

 Instructions to Part One:

      This questionnaire  consists  of  three principal  parts.
 The  first part, which  should  b e  filled o u t -first ,  consists
 of  the  attached list of  400  + chemicals identified by  EPA  as
 being  acutely  toxic when  released into the air.  Beside  each
 c h em ical  on the list are  spaces  for  you to chec kma r k  a  "YES"
 or  a  "NO", depending on  whether  your company ever  stores,
 processes, produces, transports  or  otherwise handles  eachof
 these  chemicals.  Please  chock  a  "YES* or a "NO" response
 for  each  and every  chemical  on  the  list.

 Part  Two
      For each chemical'  that  you checked "YES"  in  Part  One,
please  answer the following  questions to.th* best of  yo-ur
ability.  Please attach  plain  or  letterhead paper with  your
answers  to these questions,  but please be very'careful  to
identify the question being  answered by including the
question number with  your  response,-  identifying  the  specific
chemical being discussed   and  to  include your  company  name
oneachsheet.

.  1.  Presently, how much  (i.e.  gallo-ns, pounds,  liters,
     Hil'ograms, etc.)  of  each chemical is at your  facility?

      a.  Wha t is the mini mum,  average and maximum  quantities
         (i.e. gallons,  pounds,  etc.D  that are  on  site  at  any
         given time?

      b.  What do you use  these  chemicals for?

  2.  Explain specifically  how the  acutely toxic  chemicals  are
     handled or stored on 'site?

      a.  Are special conditions  like  high or  low  pressure,
         heating, or cooling  involved  in your handling,
         processing or storage?

      b.  In what physical  stat-eC-s) is  the chemical  found on
         site (e.g., gas,  liquified.gas,  liquid,  solid,  dust,
         p owd or)?

      c.  Are'  these chemicals  handled  or stored  near  other
         chemicals  that  are flammable, explosive,  or
         reactive?

      d.  Arc any special  precautions  token  to protect  the

-------
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-------
                              Page  2
       aculely  toxic chemical?

    a. Whore  are  these chemicals  handled or stored on  the
       site  in  relation to  tha  site  fence  line?   (Please
       submit  a  diagram of.your plant  layout indicating
       where  these  chemicals  are  stored, processed,
       handled,  etc. 3

    f. How much  (maximum,  minimum,  average) is handled  o.r
       stored  in  any one  location  at  any one time?

    g. Do you  have  contaminant  containment capacity
       a-vailable  should you  have  a  leak?

    h. If you  have  a leak  from  your  storage area  what  do
       you do  or  what  would  you do?

3 .  Ars any of  the acutely  toxic chemicals  transported  to  or
   from  your  plant?

    a. What  are  the minimum,  average  and maximum  shipment
       quantities (.in   tons-,  gallons,  or pounds, etc.)?

    b. Is  the  substance shipped by. rail,  truck, barge  or
       other  mode and   in  what  kind  of  container (drums*
       bags,  tank v/agons,  etc.)?   Specify.  Please  also
       give  'the  name of the  haulers  used.

    c. How  frequent are the  shipments  and  at what time  of
       day?

    d . What  are  t h-e transport  routes  through  the  c omm u n i t y
        to  and from  the  site?

 4.    Have  you-ever had  an  acc'i dental   releaieCs) of  one of
        the  lisled chemicals  into  the  environment?

    a.  If  so how much  v/as  released and  describe how the
       a c c i d e n t ( s )  occurred.

    b. Describe   the response efforts  taken.

    c. What  does your  company d-o  io prevent  releases of
        this  type?
5.  Do  you have any special  on-site  transfer  procedures
    betsvcen tha transport  vehicle and  on-site  storage
    equipment  for chemicals  that are on  t h,e  list?

6.  Do  you hove any special  on-site  transfer  procedures
    between storage and  process equipment?

7.  Do  you have any safety control devices  in  place on

-------
                     . t c . > ?
                                              "'J">«""'t
9. Do  you  h
             have a  routine plan  and schedu
                                               e  for
 11.  i
    * the  area  around  the slte best  dc3Cribod  as
      * Residential?
      x Comme r c i a I ?
      * Industrial?
      * Mixed?
      * Agricultural?
      ^Spccialuae/institutiona!?
      ^Openapace?
12. Do  you  have a  safety plan  Caiao refer

    site  p-lan coo r d i-n a t e d- w i t h  the  local"3
    contingency plan?

     a. Do  you have available on-site  emergency response
        equipment  (e.g., firefiahtiiia  *»n  "     t         "
        protective cquipm,,.,*, commun i ca I i oST^qu i pmen' U "and
        trained personnel  to provide  on site  initial
        r cspon s e  e f f o r t s ?                          ^ ' a i

     b. What  equipment  is  available?   Ce.g  ,  positiv-
        pressure  respirator, chemical  suits,  unmanned  fir-
        monitors,   foam 
-------
are  the  employees  trained  to  use
of  an amergancy?
                                                  t h a m  in  the  event
      ( , Wh at  kind  of  line notification  s y s t a m  do  you  havs.
         between  the site and  local  co mm uni ty emergency
         services  Ce.g.,  direct  alarm,  direct telephone
         hook-up,  computer hook-up)  to  address  emergencies
         o n- s i t e ?

      g. Does  tho  site  have  a  mechanism  to  alert  employees
         and  the  surrounding  community  in  the event  of  a
         release?

      h. How  does  the  ; i t e educate  the  co mm unity  about  the
         meaning  of  various  alarms  or  warning systems?

      i. How  docs  the  site coordinate  with  the  co mm uni t y
         government  and  local  emergency  and  medical  services
         during  emergencies?'

      j. Does  the  site  have  any  mutual  aid  agreements  for
         obtaining  emergency  response  assistance  from  other
         industry members?   If  so,  what  are  th-y  and with
         whom?

      k. Does  the  site  have  any  contracts  or  other
         pre-arrang erne n t s in  place  with  cl-eanup  specialist
         for  cleanup and  removal  of  releases, or  is  this
         handled  in-house?  What   is  therespons-e  time?

      I. How  does  the  site determine  concentrations  of
         released  chemicals  existing  at  the  site?   CArs -there
        • toxic  gas  detec-tors,  explosimeters,  or  othe'r
         detection  devices positioned  around  the  site?   V/h ere
         are  they  located?}

      m. Does  the  site  have wind  direction  indicators
         positioned  within the  sits  perimeter to  determine
         in what  direction a  released  chemical  will  travel?
         Where  arc  they  located?

      n. Do you  have the  capability  for.  modelling  vapor cloud
         dispersion?

      o. Does  the  site' have  available  auxiliary  power  systems
         to perform  emergency  system  functions  in  case  of
         p owe routages?

      p . How  often  is  your safety plan  tested and  updated?

13.  Do you have  a  safety training  plan  for  your  employees?

      a. Are  your  employees  trained  in  the  use  of  e.mergency
         response  equipment,   personal  protective  equipment,

-------
                                 Page 5
         and emergency  procedures  detailed  in  the plant
         safety  plan?   How often  is training  updated?

     b.  Does  the  sits  hold  simulated emergencies for
         training  purposes?   How  often?   How  are  these
         simulations  evaluated  and  b.y whom?   Are  the  local
         c o mm unity  emergency  response and 'medical service
         organizations  invited  to  participate?

     c.  Are employees  given  training in  methods  for
         coordinating  with  local  co mm uni t y  emergency  response
         and medical  services  during emergencies? How  often?

    Does' the  site  have an emergency response  equipment  and
    systems in'spection plan?

     a.  Does  the  site  have  a  method' for  identifying
         emergency  response  equipment problems?   Describe   it.

     b.  Is  there  testing of  oil-site alarms,  warning  signals,
         and emergency  response  equipment?   How often  is  this
         equipment  tested and  replaced?
Part Th r e e
1.  In  addition  to  the chemicals  .that you  indicated  "YES "
    responses  to  in  Part One,"do  you have  any chemicals  on
    si te  tha-t. might,  generate  by-products,  waste products, or
    combustion products ' C i n  .the  event of
    t h e  I i s t ?
                                              fire} that  are  on
      a.  If so, what  chemicals  do you  have  a'nd w h* i c h  of  the
         chemica'1'3  on the  list  could  they  generate,   and how?

      b.  Hov/much  of  each  chemical  is. on  the site?  What is
         the  range  of inventory (average,  maximum,  minimum!!?
Please  sign,
                    end return  your response to:
                                                        (qu e s t )

-------
 Dear  Sir:

 As you  are  aware,  there is  increasing public concern about releases of toxic or
 potentially toxic  contaminants  into  the  environment.  This release may be the
 result  of routine  use  or accidental  spillage.   Quantities released may be
 within  permissible limits or  in  excess of  safe levels.   Your help is needed by
 the      "         Air  Pollution  Authority  to gather information on toxic
 material usage  in       County^.

 The enclosed  questionnaire  was developed to  learn  more  about the usage of toxic
 chemicals associated with various  businesses within the community.  Please look
 over  the attached  list  of chemicals  for which  we will  be evaluating usage infor-
 mation.

 Please fill out the enclosed  questionnaire,-  keeping in  mind  we  are trying to
 find  an "annual" usage  value.  The instructions for completing  each sheet are
 included.   If additional help is needed, please contact the  ...       '      Air
 Pollution Authority-at  '      '    We  recognize the questionnaires  are  complex,
 but your help _is essential  in getting good information  for the .community.

Manufacturers and  suppliers of solvents, resins, and other chemicals will  soon
 be required to provide  you  with MATERIAL SAFETY DATA SHEETS  for  toxic  chemicals.
 If you already have thes_e available for those  chemicals you  use,  please  provide
 a copy when you return  the  survey.
Please return the survey by
be available to interested persons by
please indicate so on your questionnaire.

Thank you for helping.

Sincerely,
   Survey results for        should
'•  .   If you wish a survey summary,
                Qeon Air !s a Natural Resource - Help Preserve It

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                                        Table 1

                              POTENTIAL!.! TOXIC  COMPOUNDS
  75-07-0
  107-02-3
  107-13-1
  309-00-2
  107-05-1
  92-67-1
  61-82-5
  7740-36-0
  7740-38-2
  1332-21-4
  71-43-2
•  92-87-5
  50-32-8
  100-44-7
  7440-41.7
  608-73-1
  58-84-9
  111-44-4
  542-38-1
  111-42-2
  7 440 .43 _g
  133-06-2
  63-25-2
  56-23-5
  76-13-1
  133-90-4
  12789-03-6
  108-90-7
  510-15-6
  67-66.-3
  107-30-2
  126-99-8
•7440-47-3
  1319-77-3
  50-29-3.
  96-12-3.
 25321-22-6
 91-94-1
 94-75-7
 60-57-1
  117-31-7
 79-44-7
 57-14-7 '
 77-78-1
 SEQ-128
  123-91-1
 115-29-7
 72-20-3.
 106-39-3
 142-59-6
 106-93-4
 107-06-2
 75-21-3
 96-45-7
 1 = 1-56-4
 106-39-3
 50-00-0
 76-44-8
 Aca taldehyde
 Acrolein
 Acrylonitrile / Propenenitrile / Vinyl Cyanide
 Aldrin
 Allyl Chloride
 4-Aminodiphenyl / 4-Aminobiphenyl / P-Biphenylamine
 3-Amino-1, 2, 4-Triasole / 5-(4-Acstaminodiphenyl)-3-Amino-5-Triazole Hydrate
 Antimony and Compounds
 Arsenic and Compounds
 Asbestos
 Benz ene  •
 Benzidine / 4,4-Biphenyldiamine / 4,4-Dipfaenylenediamine
 Benzo (a) Pyrane / 3, 4-3enzopfarane / BAP
 Benzyl Chloride
 Beryllium and Compounds
 BKC / 1, 2, 3» 4, 5, 6-Eexachlorocyclohexane
 Lindane and Isomers
 Bis (2-Chloroethyl) Eth'er
 Bis (Chloromethyl) Ether / Chloro (Chloroethoxy)' Methane / BCME
 Bis (2-3ydroxyethyl)-Dithiocarbamic Acid / Potassium salt
 Cadmium and Compounds
 Captan
 Carbaryl
 Carbon Tetrachloride / Tetrachloromethane
 CFC 113              '                       •
 Chlcramben
 Chlordane
 Chloro benzene
 Chiorobenzilate
 Chloroform /  Trichloromethane
 Chloromethyl  Methyl Ether /  CMME     .   .
 Chloroprene                 •               .    .         •
 Chromium and  Compounds (Hexavalent)
 Cresola  / 0,«,P-Cresol / Cresylic Acid
 DDT/DDD
 1,  2-Dibromo-3-Chloropropane
 Dichlorobenzene
 2,  3-Dichlorobenzidine / 3,3  Dichlorobiphenyl 4,4-Diamine
 2,4-Dichlorophenoxy Acetic Acid / 2,4-D
 Dieldrin
 Di  (2-Ethyl Hexyl  Phthalate)
•Dimethylcarbamyl  Chloride / Dimethylcarbamio Acid  Chloride
 1,1-Dimethyl  Eydrazine / Asymmetric Dimethyl Hydrazine
 Dimethyl Sulfate
 Dioxins
 Dioxane  /  1,4-Diethyleae Dioxide  / Glycole  Sthylene  Ether
 Endosulfan
 Endrin
 Spichlorohydrin
 Ethylenebisdithiocarbamic Acid Salts
 Ethylene Dibromide  /-1,2-Dibromoethane
 Ethylene Dichloride /  1,2-Dichloroethane
 Ethylene Oxide /  1,2-Sponyethane
 Ethylene Thiourea / 2-Imidazolidinethione / 1,3-Sthylene-2-Thiourea  / ETU
 Ethyleneimine
 Epichlorohydrin /  1-chloro-2,3-Epoxypropane
 Formaldehyde
 Heptachlor
     AS1S06

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                                APPENDIX G

                 EXAMPLE INDUSTRY SPECIFIC QUESTIONNAIRES
     The following sample industry-specific questionnaires  are examples
only and are provided as a resource of information.   They are  not  to  be
reused and are not endorsed or recommended for use,  nor do  they represent
flawless examples.  Each agency should tailor questionnaires  to the
specific needs of the area.
                                   6-1

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                                                          FOR AGENCY OSS ONLY
                                                            County     Plant I. D.
                                                SIC
                         SIC
                                                                           SIC
                       TOXIC AIH CONTAMINANT EMISSIONS SURVEY FORM
                                   General Information
 1.   Company and Division
 2.   Mailing Address
Street
Number of Employeel
     City
State
Zip Code
 3.   Person to Contact
Title
Telephone Number
  .   Plant Location (including name of locality)
            UTM Coordinates
 5.   X Coordinate.   Y Coordinate    UTM Zone
             .  Plant Elevation above M. S. L.  (ft).

6.
7-
8.
9-
10.
General Nature of
Annual Production
1934 Production by
Dec - Feb , ,.
Mar - May 	
If You Incinerate
Type of Waste
Amount Burned
Name of the Owner
Business
(1934)
Season:
% Jun - Aug 	 , ._., %
_ % Sep - Nov 	 %
Any Wastes, Indicate:
(Tons / Year)
„
or Responsible Official Title
11.   Signature
                Date

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                                 INSTRUCTIONS  FOR
                             "GENERAL  INFORMATION"  FORM

If your facility does not use or generate any  of the  substances  listed ia the table
of Potentially Toxic Substances (Table  V), please  complete  only  this General
Information Form.  At the bottom of the form,  indicate that.there are no toxics at
your plant site and return the form to  the DEQ.

If there are questions on any of the  ferns that you are  unable to answer,  leave
those questions blank.  Whenever available, include copies  of the Material Safety
Data Sheets when the questionnaires are returned to the  DEQ.

If you have any questions, olease call
 1 .
 2.
 3-
 '4.
 6.
  ' '

 7.

 8.


 9.


10.



11.
     Conicanv and Division and Date of Subnlt'tal — —  Specify  the  name  under  which "he
     company operates and the division, if it is a  subdivision  of  a  larger company.

     Mailing. Address and Number of Employees — Show  the mailing  address  for  the
     plant, not the headquarters address. - List the approximate number  of  employees
     at the plant.

     Person to Contact — • Indicate the name, title,  and  phone number of the person
     at the plant to contact concerning the information  on  these forms.

     Plant Location — If different than the mailing address, locate the plane  by
     its actual street address.            •         "  '

     .HTM Coordinates.  Plant Elevation — Show the DTM  X  coordinate,  1 coordinate,
     and UTM zone, if known.  Show the plant elevation above mean  sea level in  feet.

     General Mature of Business — • Describe the major  products  or  services of  the
     plant.  Provide .the Standard Industrial Code (SIC), if known.

     Annual. Production — Indicate the annual production and include units 'for  198*1.

     Production bv Season..-- Show the percentage of  the  yearly  production  that  takes
     place in each season.

     Waste Incineration — If any wastes are incinerated on site,  indicate the  type
     and amount of waste burned.   Attach a separate  sheet,  if necessary.

     Naae of Owner or Responsible Official, and Title —  Indicate the na
     of the plant owner or official responsible for  the  information  supplied on
     these forms.

     Signature and Data — Include  the signature of  the  owner or responsible
     official and She  date the form is signed.
     IF YOUR COMPANY USES,  STORES OR HANDLES ANY COMPOUNDS CONTAINING CHEMICALS
     LISTED IN THE  ATTACHED  TABLE OF "POTENTIALLY  TOXIC  COMPOUNDS" (TABLE 1),
     PLEASE COMPLETE ALL APPROPRIATE ATTACHED FORMS.

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                                    STORAGE TANKS
    (LIQUID FUELS, SOLVENTS, HYDROCARBONS, AND OTHER VOLATILE ORGANIC COMPOUNDS)
1.  Company Name
                                Plant Location
  Information for
Calendar Year i
2. Tank Identification
3. Type of Storage Tanks:
Above/Below Ground
Fixed/Moveable
4. Name 4 Vapor Pressure
of Material Stored
(Attach Material Safety
Data Sheets if Available)
5. Density of Material
Stored:
(Ib / gal)
6. Tank Capacity (Gallons)
7, Throughput (Gallons)
8. Submerged or Splash Fill ;
9. Pollution Control Equipment:
Type of Control Equipment
Estimated Efficiency (?)
10, Emission Rate
(Tons/Ysar)
(Attach Calculations)
1 1 . Toxic
Identification No.
(From Table 1)
12. Amount of Toxic in
Stored Material (Vol Jf)
•

































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                               INSTRUCTION FOR

                            "STORAGE TANKS" FORM
 3.


 4.
 o.

 7-


 8,


 9-




.10,
Company  Name.  Plant  Location,  and  Information for Calendar Year —
List  the  company  name  and plant location.   Mote that all information
should reflect calendar year 1984  conditions.

Tank  Identification  — Assign an identifying number or name to each
storage  tank,  which  contains a Volatile Organic Compound (YOG)-.   A VOC
is any organic compound with a vapor  pressure greater than 0.1 ma Eg
at standard  conditions (20°C and 760  mm Eg).   Seme YOCs are sola under
trade names  or common  names  such as Amsco,  Socal,  Mineral Spirits,
paint thinner,  Cellosolve, Naptha,.DeYoe,  Stoddard,  Yorinal,  etc.
Seme  are  sold  under  their actual chemical  name,  such as formaldehyde,
perchloroethylene, alcohols,  styrene,  xylene,  toluene,  and ke cones.

Tvue  of Storage Tank — Indicate whether the storage tank is  above or
below ground;  and whether it is fixed or moveable.
                     i »
Wage  and  Yaoo-r Pressure of Material Stored — Identify the chemical
or brand  name  for each material stored.  If a brand name is used,
please attach  the manufacturer's Material. Safety Data Sbeec or other
information  on the material's  chemical composition.   For each
material,, list the vapor  pressure, if known.

Density of Material  Stored —  For  each chemical  stored,  provide  the
density (pounds/gallon).

Tank.Capacity  — Specify  each  tank's  holding capacity in gallons.

Annual Throughput -— The-  number of gallons of each material which
passed through each  tank  in  1984.

-Submerged or Salash  Fill  —-Indicate  whether  the tank is filled  using
submerged or splash  methods.

Pollution Control: Equipment  —  For each  tank  indicate type  of control
equipment and  efficiency.  Some typical  types  of pollution controls
for tanks are  vapor  adsorption,  incineration,  refrigerated liquid
scrubber, floating roof,   etc.

Material Emission. Hate —  If emission factors  are  known,  estimate  the
number of tons  of YOG escaping  from the  tank  due to  tank breathing and
working losses.  Please attach  your calculations.   If emission rates
from this tank  are not known, leave this blank.  The  emission rates
will be calculated using  published emission factors.
12.
Toxic Identificstion Number -— Determine  the chemical  composition  of  the
stored material using Material Safety Data Sheets, other information
supplied by the manufacturer, or personal knowledge.   If any of these
substances are listed in the table of Potentially Toxic Compounds  (Table
1), enter the identification number from  the table.  Space is left for
four toxic compounds to be identified for each storage tank.  Use
additional columns for the tank or add additional sheets if more than
four toxic compounds are contained in the stored material.

Amount of Toxics in Stored Material — Show the percent by volume  of
the toxic in the stored material.
AH347.1A
August 1985

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                                     DRY CLEANING
  1.   Company Name
Plant Location
                Information for
              Calendar Year 1Q6
  2.   NORMAL OPERATING SCHEDULE:

           	 hrs/day
                days/week
                       weeks/year

      APPROXIMATE PERCENT OF SEASONAL SALES:
           Dec - Feb
           Jun - Aug
             Mar
             Sep
May
Nov
      TYPE,  AMOUNT,  AND DENSITY OF SOLVENT CLEANER PURCHASED US 1984:

                          Type/Amount	               Penalty
           Per chl or oe thyl ene
           Stoddard Solvent
           Other (Specify)
           Other (Specify)
          gallons/year
          gallons/year
          galIons/year
          gallons/year
                         Ibs/sai
                         Iba/sal
                         Ibs/gal
                         Ibs/gal
     . SOLVENT' RECYCLING:
           ?sr chl or oehy ly ene
           Stoddard Solvent
           Other (Specify)
                                Amount of Solvent
                              Sent for Reprocessing
                                   or Disposal
                                   (Gal/Year)
                            Amount of Solvent
                              Returned from
                               Reprocassias
                                 (Gal/Year)
  o.
      METHOD OF DISPOSAL OF STILL BOTTOMS AND/OR SPENT  FILTERS:
           PLEASE ATTACH MATERIAL SAFETY DATA SHEET FOR  ALL  SOLVENTS  USED,
                               EXCEPT PERCHLOROETHYLENE
AH347.2
August 1935
                                     DEQ  ?OHM  HO.  18533

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                               IHSTHUCTION ?OH

                             "DRY CLEANING" FORM


 1 .    Company Mame. 'Plant Location,  and In-foraation for Calendar-Tear —
      Specify the company name and plant location.  Mote that all
      information should reflect calendar year 198^ conditions.

 2.    Normal Operating. Schedule — Indicate how many hours/day,  days/week
      and weeks/year  you usually operate.

 3-    Approximate Percent of Seasonal Sales — Show the approximate percent
      of the yearly  sales that occur in each season.

 4.    Tvoe.  Amount and Density of Solvent — Scecify the amount  of each
      type of solvent purchased in 1984.  If any solvent other than
      perchloroethylene is used,  please attach the Material Safety Data
      Sheet or other  manufacturer's  information on the chemical  composition
      of the solvent.

.$.    Solvent Recycling — Indicate  the number of gallons in 1984
      reprocessed outside your facility or disposed of by methods other than
      reprocessing.   If applicable,  specify the gallons of solvent in 1984
      that were returned to the plant after reprocessing to be reused.

 6.    Method of Disposal of Still Bottoms and/or Spent Filters — Describe
      the methods of  disposal  if done on site,  or indicate the disposal
      company which  removes this waste.
 AH347.2A
 August  1985

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              USE OF,WASTE OILS,  RECYCLED OILS AMD/OR SCL7EHTS FOR FUEL
Company Name Plant Location Information for
Calendar Year 12M
1.
2.
3.
4.
5.
6.
Boiler or Burner I.D.
Source of Waste Oils,
Recycled Oils, and/or
Solvents
Type and Amount of Waste Oils,
Recycled Oils, and/or ' •
Solvents Burned in Unit
ia 1984 (Gal/Year)
Toxi-e Materials in -Oils
or Solvents
(.Use Table 1)







Type and Efficiency of
Pollution Control Equipment
Operating Eoiirs Hours/Day
When Using Days/Week
Waste/Recycled Week/Year
Oils or Solvents





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AH347-3
August 1985
DEQ FORM HO. 16337

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                              INSTRUCTIONS  FOR

       "USE OF WASTE OILS, RECYCLED  OILS, AND/OR SOLVENTS FOR FUEL" FORM
      Boiler or Burner I.D. — Your  identification for the boiler or burner
      using the waste oils, recycled oils,  and/or  solvents.   Up to four (4)
      burners can be identified on each  form.   Please  make additional copies
      of the _form as necessary.

      Source of Waste Oils. Recycled  Oils,  and/or  Solvents — Indicate the
      process that generated the waste oil  or  solvent  or  the  supplier that
      delivered the recycled oil or  solvent.

      Tvpe and Amount of Waste Oils.  Recycled  Oils,  and/or Solvents
      Burned — Enter the amount (gallons)  of  waste  or recycled oil  or
      solvent and the grade(s) burned in each  boiler or burner.

      Toxic Materials in Was'te Oils.  Heoveled  Oils,  and/or. Solvents  — If
      information such as Material Safety Data sheets,  other  oanuracturer's
      or suppliers information, or personal knowledge  exists,  determine  the
      chemical composition of the oils or solvents.  If any of the
      substances are listed in the table of Potentially Tcxic Compounds
      (Table 1), enter the identification number from  the  table.   Space  is
      left for four (4)  toxic compounds from the table to  be  identified  for
      each burner.  Use  additional columns  for  the operation  or  attach
      "additional sheets  if there are more than  four  (4) toxic compounds  in  .
      the oils or solvent.

      Tvpe and Efficiency of Pollution Control  Equipment — Describe  the
      boiler or burner control equipment, if any, and  the  estimated
      efficiency.

      Operating 'Hours --'indicate the hours that the boiler operated  in  1984
      when all or part of the  fuel was waste/recycled  oils or  solvents.
 AH347-3A
.August  1985

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                     DECREASING, CLEANING, AND SURFACE  PREPARATION
    1.  Company Name
Plant Location
           Information  for
        Calendar  lear  1Q8U
2.
3.
4.
5.
6.
7-
8.

9.



10.


11.



Operation Identification
•
Type of Operation . j
(Use Code 1)»
I
Type of Solvent
(Attach Material Safety
Data Sheet) !
Amount of Solvent
Purchased in 1984 (Gal)
i
Amount of Solvent Sent for i
Reprocessing or Disposal ' !
in 1984 (Gal)
Amount of Solvent Returned '
After Reprocessing in 1984 j
(Gal)
Waste Solvent Disposal j
Method (Use Code 2)**
i
Toxic Identification No.
(From Table 1) ' ! ' ' - .
• i

Amount of Toxics in • i ,
Solvent (Volume ?) \ 	
1 '
Emission Rates i
Based on Stack (Attach !
Test/Material Calculation')
Balance ;


!


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          * Code 1 — Type  of  Operation

           A. Cold Cleaner
           B. Open Top Vapor
           C. Conveyorized, Vapor
           D. Conveyorized, Non-Boiling
           E. Surface Preparation
           F. Other (Please Specify)
           **  Code 2
Disposal Method
              A.  Discharged into Sewer
              B.  Reclaimed by Salvager
              C.  Sent to Treatment,  Storage
                 or  Disposal Facility
              D.  Incinerated
              E.  Other (Please  Specify)
AH347.4
August 1985
                                  DEQ  FORM NO.  18634

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1.



2.


3^


4.
 5,


 6.



 7«



 8.


 9-
10.
                              INSTRUCTIONS FOR
            "DECREASING, CLEANING,  AND  SURFACE PREPARATION" FORM


     Company Mame. Plant Looation.  and Calendar  Year Information — Specify
     the company name  and location.  NOTE:   All  information should reflect
     calendar year 1984 conditions.
     Operation Identification
     each operation.
                                 Assign an identifying number  or  name  to
     Type of Operation — Using Code  1  at  the  bottom  of the form,  specify
     the type of operation.

     Type of Solvent — Identify  the  type  of solvent  used for  each
     operation (i.e., Stoddard, percfaloroetfaylene,  trichloroethylane,
     isopropyl alcohol, etc.). If a brand  name solvent  is used,  please
     attach the manufacturer's Material  Safety Data Sheets or  other
     information on the solvent's chemical  composition.

     Amount of Solvent Purchased  — List the gallons  of solvent  purchased
     in 1984 for each operation.

     Amount., of Solvent Sent for Reprocessing, .or... Disposal — Indicate  the
     number of gallons in 1984 reprocessed  outside  your facility or
     disposed of by methods other than  reprocessing.

     Amount of Solvent Returned after Reprocessing  — If applicable,
     specify the gallons of solvent. in  1984 that were returned to  the plant
     after reprocessing to be reused in  the indicated operations.

     Waste Solvent Disposal — Using Code 2 below,  indicate which  disposal
     method was used in- 1984 for waste  solvents.

     Toxic Identification Number — Determine  the chemical composition  of •
     the -solvent using Material Safety Data Sheets, other  information
     supplied by the manufacturer or personal  knowledge.   If any of the
     substances in the solvent are listed in the table  of  Potentially Toxic
     Compounds (Table '1>, enter the identification  number  from the  table.
     Space is left for four toxic compounds from the  table to  be identified
     for each operation.   Use additional columns for  the operation  or
     attach additional sheets if  there are more than four  toxic  compounds
     in the solvent.

     Amount of Toxics in Solvent — Show the percent by  volume of any
     compound listed in the table of Potentially Toxic  Compounds (Table 1)
     contained in the solvent.

     Emission Races — If data from a stack test or material balance are
     available,  list the expected emission rates (lb/1000  gal) for  each
     compound from the table of Potentially Toxic Compounds  (Table  1).
     Please attach your calculations.   If no stack  tests or  material
     balances are available,  leave this blank.   The emission rates  will be
     calculated using published emission factors.
AH347.4A
August 1985

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                                    PESTICIDE USE
  1.   Company Name
Plant Location
  Information for
Calendar Tear io8
2.
3.
4.
5.
6.
7-
Name of Pesticide
(Attach Material
Safety Data Sheet)
Amount of Pesticide
(Lb/Yr) or (Ft3/Yr)
or (Gal/Yr)
Density of
Pesticide (Lb/Gal)
or (Lb/Ft3)
Name(s) of Solvents
Added to Pesticide
Amount of Additional
Solvent (Gal/ Year)
Density of Additional
Solvent (Lb/Gal)









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AH347-5
August 1985
                                       DEQ FORM NO.  1683!

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                              INSTRUCTIONS FOR

                            "PESTICIDE USE" FORM
  1•   Company Wame.  Plant  Location.  Information for Calendar Year — List
      the  company name  and plant location.   Note that all information should
      reflect calendar  year 1984 conditions.

  2.   Name of Pesticide — List  the  brand name of pesticide(s)  used during
      storage and transfer operations in 1984.  There are up to three (3)
      pesticides  that can  be  identified on this form.  Please make
      additional  copies as necessary.   Attach Material Safety Data Sheet or
      other manufacturer's information for  each pesticide.

  3«   Amount  of Pesticide  —•  List  the amount  of each pesticide  purchased in
      1984.    If  the pesticide was purchased  in a solid form, list the
      pounds/year; if purchased  in a gaseous  form,  indicate cubic feet/year;
      if purchased in liquid  form, use gallons/year.   Indicate  the
      appropriate units (lb,  gal,  f t^).

  4.   Density of  Pesticide — If the pesticide was  purchased in a liquid or
      gaseous  form, indicate  the density of the-pesticide,  if known.

  5.   Msgefa)  of  Solvents  Added,  to..Pesticide  — If  any additional solvents
      are  added to the  pesticide before  application,  list the chemical name
      of the  added solvent.   If  a brand  name  solvent  is used, attach the
      Material Safety Data Sheet or  other manufacturer's information on the
      solvent  composition.        .            .                        .

  6.'   Amount  of Additional Solvent —  List  the gallons of solvent added to
      each  type of pesticide during  1984.

  7.   Density of  Additions! Sol-rent  — List the density of  the  added
      solvents, in pounds  per gallon,  if known.•
AH347.5A .
August 1985

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                                 SUHFAC3 COATING OPERATIONS
Company Name . , Plant Location Information for
Calendar lear 1Q8^
1.
2.
Description of Coating
Operation
Type and Amount of
Coating Purchased
(Attach Material Safety
Data Sheets)
3« Density of Coating
Purchased
(Pounds /Gall on)
4.
5.
6.
7.
a.
Percentage of Solvent in
Purchased Coating
(Tolume $)
Type and Amount of
Solvents Added to Coating
(Attached Material Safety
Data Sheets)
Type and Efficiency of
Control Equipment
Toxic Identification Nos.
(From Table 1)
Emissions of Toxic
Compounds











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AH347.8
August 1985
                                                                     DEQ  FORM NO.  16838

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                              INSTRUCTIONS FOR
                      "SURFACE COATING  OPERATIONS" FORM
1.   Description of  Coating Operation —  For  each coating operation at your
     plant, include  type  of 'application  (spray,  roller,  brush,  saturation,
     lamination, etc.) and assign  an identification name or  number.   Up to
     three  coating operations  can  be described  on each form.   Please make
     additional copies of the  form as necessary.
                            •
2.   Tvoe and Amount, of Coating  Purchased —  Indicate  type of coating
     (ink,  paint, varnish, lacquer, enamel, stain,  adhesive,  resin,  etc.)
    • purchased and amount (gallons) used  in 1984.   Attach Material Safety
     Data Sheets from the coating  manufacturer.

3-   Density of Coating Purchased  — Density  of the coating  as  received
     from the manufacturer in  pounds per  gallon.

4.   Percentage of Solvent in  Purchased,,Coating —  Percentage (by  volume)
     of each solvent in the coating as received from the manufacturer.
     Some examples of solvents are:  thinner, mineral  spirits,  cellosolve,
     naptha, socal,  reducer, kerosene, ketones,  alcohols,  styrene,  xylene,
     toluene, etc.

5.   Type and Amount of Solvents Added to Coating — Indicate the  name and
     amount (gallons) of  each  solvent added to  the  purchased  coating prior
     to application.  If  a brand name solvent is  used,  please attach the
     Material Safety Data Sheet  or  other  manufacturer's information on the
     chemical composition of the solvent  added  to  the  coating.

6«   Tvoe and Efficiency  of Control Equipment --  Describe any control
     system which reduces emissions of the solvents  or  coatings, and
     estimate the efficiency (?) of the 'control  system.   Types  of  control
     equipment include water wall,  gas fired afterburner,  etc.

7-   Toxic Identification Number — Determine the  chemical composition of
     the solvent using Material  Safety Data Sheets,  other information
     supplied by the manufacturer  or personal knowledge.   If  any of  the
     substances in the solvent are listed in the  table  of Potentially Toxic
     Compounds (Table 1),  enter  the identification  number from  the  table.
     Space is left for four, toxic  compounds from  the table to be identified
     for each operation.   Use additional  columns  for the operation or
     attach additional sheets if there are more  than four  toxic compounds
     in the solvent.

3.   -Emission of Toxic Compounds — For any compounds listed  in the  table
     of Potentially Toxic Compounds (Table 1)  which  are  released during the
     coating operation or  subsequent curing,  calculate  the amount  (in
     pounds) and attach calculations.   If emission rates  are  unknown,  leave
     this section blank.   Emission rates will be calculated using published
     emission factors or material balances.

AH347.8A •
August  1985

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                                  INSTRUCTIONS FOR
                   "PROCESSING AND MANUFACTURING OPERATIONS" FORM
  1.   Company Name.  Plant Location,  and Information for Calendar Year — Specify the
      company name and plant location.
      1984  conditions.
NOTE:  All information should calendar year
 2.   Process  or Operation Identification — Assign an identifying name or number to
      each process or operation which uses a compound listed in the table of
      Potentially Toxic Compounds  (Table 1).  Two processes or operations can be
      described on each form.   Please make additional copies of the form as needed.

 3.   Maximum  Capacity —•  List the maximum production rate for the process or
      operation and indicate units.

 4.   Toxic Identification. Number  — Determine the chemical composition of zstsrial
      used as  input to the operation or process from Material Safety Data Sheets,
      other manufacturer's information, or personal knowledge.  If any of these
      substances are listed in the attached table of Potentially Toxic Compounds
      (Table 1), enter the identification number from the table.   Attach Material
      Safety Data Sheets identifying the toxic compounds, if available.  There is
      space for four toxic compounds to be identified for each operation or process,
      Use  additional columns or add additional sheets if more than four toxic
      compounds are involved in a  process or operation.

 5.   Toxics in Feed Input. —  Show the identification number (from 4 above) and the
      amount of each toxic compound in pounds per year contained in the process or
      operation feed input.

 6.   Toxics In Product Output—  Indicate the identification number and the amount
      of  the toxic that is.incorporated into the product.

 7.   Toxics In Byproducts—  Indicate the identification number' and estimate the
      amount ('pounds per year) of  any toxic compound listed in the table of
      Potentially Toxic Compounds  (Table 1) that is not incorporated in the product.
      (For example:  A compound contained in a waste material.) Indicate the method
      of  disposal.or final use of  the toxic containing material.

 3. _  Toxics in Intermediate Products •*- Identify any toxic from Table 1 formed in
      intermediate steps of the process which has the potential to be emitted through
      storage,  transfer or accidental release.  These intermediate products may be
      completely or partially  consumed in the manufacture of the final product.
      Indicate the quantity formed in pounds per year.                         .   *  '

 9.   Toxic Salaslon Hates —  If data from material balances or stack tests are
      available, show the  expected emission rates and units for any compound listed
      in  Table 1.  Please  attach your calculations.'  If no material balance!
      information or stack tests are available leave this blank.   The emission races
      will be  calculated from published emission factors.

 10.   Stack or Tent Data — For the vent or stack for each process, provide the
      indicated parameters.   The height of the vent or stack is measured from ground
      level; the exit area is the  cross-sectional area of the opening in square feet;
      the  flow rate is in  actual (not standard) cubic feet per minute.

 11.   Pollution Control Equipment  —• If present, identify the type of pollution
      control  equipment on the operation or process and the efficiency with which it
     ' collects the toxics  emitted.

,12.   Operating Hours — Indicate  the hours per day, days per week, and weeks per
      year each process or operation normally functioned in 1984.

 AE347-9A
 August  1935

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                    TOXICS 'IN PROCESSING  AND MANUFACTURING  OPERATIONS
        Company Name
                Plant  Location
                                                                      Information-for
                                                                   Calendar  Year
     2.  Process or Operation Identification"
     3.   Maximum Capacity
     4.   Toxic Identification Numbers'
         (From Table 1)
     5.   Toxics  in Feed Input
         (1984 —  Lbs/Yr)
    6.   Toxics in  Produce  Output
         (1984 — Lbs/Yr)
    7-  Toxics in -Byproducts:
           •  Amount tLbs/Yr)
             End Use
    8. • Toxics in Intermediate Products
      •  Amount (Lbs/Yr) •
    9-  Toxic Emission -Rates  (Lba/Yr)
   10.

     Stack or

       Vent

       Data
Height
(Ft)
Exit Area
     Velocity  (Ft/Min)
Exit Volume    (ACFM)
                 Exit Teap.
                 Common Stack Points
   11•   Pollution Control
        Equipment
             Type
               Efficiency
                                 Hours/Day
   12.   Operating Hours -  1984   Days/Week
                                Weeks/Year
AH347.9
August 1935
                                                                    DEQ FORM NO. 16325

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                                 INSTRUCTIONS FOR
                  "PROCESSING AND MANUFACTURING OPERATIONS USING
                          VOLATILE ORGANIC COMPOUNDS" FORM
3


'4




5


6.


7.
10
11
     Comnanv Name. Plant Location, and Information  for Calendar Year — Specify  the
     company name and plant location.  NOTE:  All information should calendar year
     1984 conditions.

     Process or Operation Identification — Assign  an identifying name or number  to
     each process or operation which uses a Volatile Organic Compound (7CC).  A 7CC
     is any organic compound which has a vapor pressure of 0.1 mm Kg at standard
     conditions (20°C and 760 mm Hg) .  Some VOCs are sold under trade names such  as
     Socal, Amsco, Stoddard, and Callosolve; common names such as paint thinner,^
     lacquer and resin; or chemical names such as xylene, formaldehyde, methyl ethyl
     ketone, perchloroethylene, and isopropyl alcohol.  NOTE:  If any compound
     listed in the table of Potentially Toxic Compounds (Table 1) is contained in
     the VOC, complete the "Toxics in Processing and Manufacturing Operations" fora
     in addition to this form.  Up to three (3) processes or operations can be
     described on each form.  Please make additional copies of the fora as
     necessary.

     Maximum Capacity, — List the product and the maximum production rate for the
     process or operation and indicate units.

     VOC Description — Identify all Volatile Organic Compounds used as input to  che
                                                                              ' s .
     operation or process from Material Safety Data Sheets, other manufacturer
     information, or personal knowledge.  Use additional columns or add1 additi
     sheets if more than one VOC is involved in a process or operation.
                                                                                 ^
                                                                              onal
     Amount of VOCs in Feed Input • — Show the amount of each VOC in tons per year in
     the process or operation feed input.

     Amount of VOCs in Product Output — Indicate the amount of each VOC in
     tons/year that is incorporated into the product.

     VOCs in Byproducts — Estimate the amount "of each Volatile Organic Compound in
     tons per year that is' contained in any byproduct or waste.  Indicate the method
     of disposal of any waste.

     VOC Emission Rates — If data from material balances or stack tests are
     available, show the expected emission ratas and units.  Please attach any
     calculations you have made.   If no material balance information or stack tests
     are available leave this blank.  The emission rates will be calculated from
     published emission factors.

     Stack or Vent Data — For the vent or stack for each process, provide the
     indicated paramecers.  The height of the vent or stack is measured from ground
     level; the exit area is the cross-sectional area of the opening in square feet;
     the flow rate is in actual (not standard) cubic feet per minute.

     Pollution Control Equipment — If present, identify the type of pollution
     control equipment on the operation or process and the efficiency with which it
     collects the VOCs emitted.

     Operating Hours — Indicate the hours per day, days per week, and weeks per
     year each process or operation functioned in 1984.
AH347.11
August 1985

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         PROCESSING AND MANUFACTURING OPERATIONS USING VOLATILE ORGANIC COMPOUNDS
1 .
2.
3.
4.
5.
Company Name
Plant Location
Process or Operation Identification
Maximum Capacity

i
Information for
Calendar lear 1^8^
i
t
t
VOC Description and Vapor Pressure 1 -
(Attach Material Safety Data Sheets) ;
I
Amount of VOCs in
(1984 — Tons/Yr)
Feed Input

:

i
        Amount of VOCs in Product Output
        (1984 — Tons/-Yr)
        VOCs in Byproducts
             Amounc (Tons/Yr)
             Method of Disposal
    8.   7CC Emission Rates
    9.

     Stack or

       Vent

       Data
         Height
(Ft)
         Exit Area
(Ft*).
         Exit"Velocity  (Ft/Min)
         -Exit Volume    (ACFM)
                 Exit leap.
                        (UF)
                 Common Stack Points
        Pollution Control
        Equipment
                      Type
                        Z f f i ci e ncy
   11
                         Hours/Day

Operating Hours - 1984   Days/Week
                                Weeks/Year
AH347.10
August 1985
                                                                    DEQ FORM NO.  16336

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EXAMPLE 2 - INDUSTRY SPECIFIC QUESTIONNAIRE

-------
Dear Sir or Madam:
Public concern about exposure to toxic substances  has  prompted  the ^S.
Environmental Protection Agency to develop a national  strategy  for cont.oll-ng
routine emissions for air toxic contaminants.   This  strategy  include s  a
directive to states and local control agencies to  exaanne their 
-------
                                COUNTY HEALTH DEPARTMEOT

                        ASBESTOS PRODUCTS QUESTIONNAIRE
According to  the       	Directory of Manufactures,  your facility manu-
factures product's  containing asbestos.  If this  classification is. incorrect,
please check here and return the questionnaire. 	

If your  facility manufactures  products that  contain asbestos,  please complets
the remainder of this questionnaire.
1.   What are the principle products of this facility?
2.   In the  space provided below,  please record  the  quantity  vraw materials
     and  corresponding  •• .  quantities  used to  produce che  products listed
     above.
       Raw Material
Quantity Used'Clbs.)
     If  trade names  are listed  above,  please  provide  material  safety  data
     sheets or information  on  the  composition  of these chemical  compounds.

-------
3.   Please describe any ventilation systems used to reduce worker exposure f.
     hazardous air contaminants.
     Are vented emissions controlled in any way  to  reduce the quantity o~ .air
     pollutants released to the atmosphere? 	 Yes     	 No

     If yes,  please  provide the following information  for  each air pollution
     control device in use.

   Production  •   Control       Pollutant                          Basis For  ^
   Ooeration  •    Device     .  • Controlled    •   Efficiency        Efficiency
     Efficiencies should be reported in terms of weight percent removal  or  cr.e
     pollutant controlled.

     Describe  the  basis  for estimating efficiency  (i.e.,  source  test,  vender
     guaranty, etc.)

-------
A.   If known,  please record  the particulate emissions  from  each production
     operation  and  record  th'e corresponding  weight percent  of  asbestos  in
     Chese emissions.
     Production Operation
Earticulate Emissions
       (Ib/yr)	
Weight Percent
  of Asbestos

-------
                                     HEALTH  DEPARTMENT

                          TAPE  COATING QUESTIONNAIRE


1.   Please  .provide  as  an  attachment  a block  diagram(s)  illustrating  the
     following production operations:

     o    raw materials storage and handling;

     o    coating formulation and application; and

     o    tape baking.

     This  diagram  should" quantify ' the  materials .entering  and  leaving  the
     system "in addition to  storage and  feed  equipment,  mixing  tanks, and  all
     air pollution control devices.
2- .  How much tape was produced in
             Ifas.
     What is the typical chromium content of this tape?  '
3..   In  the  space 'provided  below,   please  record  the   raw  materials   and
    'corresponding      quantities used to produce magnetic tape.   •  -
         Raw Material
Quantity Used  (Ibs.)
     If trade  names are  listed  above,  please  provide material  safety  data
     sheets or information on the composition of these chemical compounds.

-------
4.   Please provide  the  following information for each  air  pollution control
     device used to control emissions from-the tape production operations.
   Production
   Ooeration
             Control
             Device
Pollutant
Controlled
Efficiency
Basis For ,
Efficiency"
1)
2)
Efficiencies should be reported in  terms of weight percent  removal of  the
pollutant controlled.

Describe the basis  for estimating  efficiency  (i.e.,  source Cast, vendor
guaranty, etc.)

-------
                              COUNTY HEALTH DEPARTMENT



                         ELECTROPLATING QUESTIONNAIRE



                                    PREFACE




Purpose



                                         •ic  -fo Bather  information


the ^airTchrondLum. nickel, and cadmium from electroplating





General Information



     The  first page of  the  questionnaire is designed to  identify ch


 of  electroplating   in   use.   Please  complete  this  page  as


 possible.
 Operating Characteristics     .                -                          '



  '    Please  complete  this  section separately, for each  tank ' in  use. '  Three

                                  •A A    Tf  there are more  than three  tames  in'
 copies of  this  section are provided.   If  there


 use. please make additional copies as necessary.

-------
                               COUNT?  HEALTH DEPARTMENT




                          ELECTROPLATING QUESTIONNAIRE'
GENERAL INFORMATION






1.   Is chrome placing performed at  this facility?




     If yes. whac type of plating is performed?




     Decorative,             	




     Hard Plating           	




     Chromic Acid Anodizing 	






2.   Is nickel plating performed at  this facility?






3.   Is cadmium plating performed at this facility?
Yes
Yes
 Yes
No
No
No

-------
TANK OPERATING CHARACTERISTICS'
Type of placing operation:.

           Placing Tank I?:

       Operating Schedule:
Surface area of plating tank:
Typical range of total current:
Type of pollution control equipment:
Estimated control efficiency:

Basis for removal efficiency:
Hr/day
 (1.  2.  3.  etc.).

	 cay/yr
 square feet

         amu res.
     Complete this page  separately  for  each electroplating, tank in "use.  Make
     additional copies of this page 'if necessary.

     Please use che descriptors provided under the general information  section
     on che previous page.

     Please number each  tank in use starting with the #1.

     Efficiency should be expressed on a weight removal basis.

     Describe the  basis  for estimating efficiency  (i.e..  source test, vendor
     guaranty, etc.).

-------
                            COUNTY HEALTH DEPARTMENT

                   LEAD BATTERY MANUFACTURING QUESTIONNAIRE

GENERAL INFORMATION                •

1.   List Che types of batteries manufactured at this facility:

     Automotive: 	  Industrial:-	•
     Other (describe):
     Provide the  following production  data  for each  battery type listed  in
     Question 1:
     Automotive'battery production:


     Industrial battery production:


     Other battery production:'   •
             Batteries
                                                                     Bacreriss
                Year

             Batteries
          Batteries
                Year

              Batteries
             Day

           Batteries
                                                 Year
                                      Day
     List Che average or typical lead .content for each battery type:

     Automotive batteries: 	 lb. lead/battery

     Industrial batteries: 	 lb. lead/battery

     Other batteries:	 lb- lead/battery

     Note:     Lead content  refers  to the total quantity of lead in. the
               battery including elemental lead in battery grids, terminals,
               and lead compounds in  the active material of battery places.


     List  the  percent of each  battery  type  manufactured using open formation
     and closed formation processes:
      Automotive  batteries:

      Industrial  batteries:

      Ocher batteries:
%  Open Formation
%  Open Formation

%  -Open Formation
% Closed Formation

% Closed Formation
% Closed Formation

-------
 PROCESS  INFORMATION
A.   GRID CASTING

1.   For each battery  type,  list the percent lead and the percent  of alloying
     metals contained  in the battery grids:
     Automotive batteries:
     Industrial batteries:
          Other batteries:
                               Lead
                               Lead
                                Lead
       (List metal)

       (List metal)



       (List 'metal)

       (List metal)



       (List metal)
                                                  .  (List metal)
3.

1.

2.
LEAD OXIDE PRODUCTION

Is lead oxide produced on-sita?
xes
            No
For on—site lead  oxide  production,  identify  the  process  used Co produce
the lead oxide :
     Barton

     Other
                                     Ball Mill
3.   If fabric  filters  are used  to control  air emissions  from  on-site lead
     oxide production, list the-air  to  cloth  ratio (4:1, 3:1,  or-2:1)  of the
     filter:

     Air to cloth ratio:                                                      •  ,

-------
c.

1.

2.



D.

1.
LEAD RECLAIM

Is a lead reclaim furnace used ac this facility?
                                Yes
                                           No
If a  lead reclaim  furnace  is used,  approximately what  percent of  the
total lead processed at the facility is reclaimed in the furnace? 	~
FORMATION

Provide the following information for closed formation processes:

Automotive batteries: Length of charging cycle      ._ Hours

                                 Charging rate	

Industrial batteries: Length of charging cycle 	

                                 Charging Rate	

     Other batteries: Length of charging cycle	

                                Charging cycle 	
                                                           Amps

                                                           Hours

                                                           Amps

                                                           Hours

                                                           Amos
E.   AIR POLLUTION CONTROL EQUIPMENT

1.
Provide' the  following information for  each'air pollution control- devics
used at  the facility:  •
 Control
  Device
         Process  •
         Controlled
                             Pollutant
Controlled   . Efficiency    Basis for Efficiency'
 2

 3
 Process   controlled   refers   to   manufacturing  processes   such  as  grid
 casting,  pasting,  formation,  etc.

 Report efficiency  in weight  percent removal of controlled  parameter.

 Describe the basis  for estimating efficiency  (i.e..  source  test,  vendor
 guaranty, etc.).

-------
5.   What is the volume of cooling' water used  (i.e.,  fresh water added- to  the
     system)? 	 gallons/hr

6.   Is the cooling water recycled?  	 Yes   	 No

    .If yes, how much cooling water is removed through blowndown?

     	 gallons/hr

     What is the quantity of water recycled?  	 gallons/hr

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                              COUNT? HEALTH DEPARTMENT

                          COOLING TOWER QUESTIONNAIRE
1.   Is a cooling tower (or towers) used at this facility?
                                                           Yes
                       No
     If a  cooling  tower  (or  towers)  is not used,  complete  only question or.a
     and return this questionnaire.  If a cooling tower is used, please answer
     the remaining questions.

     What type of cooling fewer(s) is used?

     	 Mechanical draft evaporative cooling tower
                            »
     	 Natural draft evaporative cooling tower                     , •

     	 Other, please describe:	——
3.
In the  space  provided below, please list  the chemical additives used  in
.the cooling tower.   If  known,  also record  the  quantity of each chemical
used and/or its concentration in the cooling water.
      Chemical Additive
                        Amount Used  (l.b/yr)
  Concentration in
the Coolinz Water (pom)
     If you  have  recorded trade  names  in the space  above,  please submit  the
     material safety data sheets for these chemical compounds.

4.   If  a  cooling  tower  is  used  in  conjunction  with  electrical  power
     generation, what is the thermal energy input to the power plant:

                                  BTU/hr

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                          COUNTY HEALTH DEPARTMENT
               'SEMICONDUCTOR MANUFACTURING QUESTIONNAIRE
1.   Are semiconductors manufactured at this facility?
                                                         Tes
                                                                         No
2.
 If semiconductors  are not  manufactured,  complete only  question  one and
 return this  questionnaire.   If  semiconductors are  manufactured,  please
 answer the remaining questions.

 In the space provided below, please record the volume of organic solvents
 that  are  both purchased and disposed (or recycled):
 Solvent
 Acetone
 Benzene
 n-3utyl Acetate
 Cellosolve  (glycol  ethers)
 Chlorobenzene
 Ethanol
 Ethylene Glycol
 Freons
 Kexamethyldisilazane  (HMDS)
 Isopropanol
 Methanol
Methyl Ethyl Ketone (MEI<)
 Methylene Chloride
 Petroleum Distillates
 Phenol
Tetrachloroethylene
Toluene
1.1.1-Trichloroethane
Tricholroethylene
Xylene
                                     Quantity Purchased
                                         (gals/yr)
                                                               Quantity Disposed
                                                                 (or Recycled)
                                                                   ( gals/yr)
12-month period "for information provided above

-------
3.   If cellosolve  ±s  used,  please identify  the  specific derivative  that  is
     used  (e.g.  glycol  monobutyl ether):

                                                             Quantity Disposed
                                                               (or Recycled)
                                                                 ( gals/vr)
         Derivative
Quantity Purchased
    (gals/yr)	
4.   In the  space provided  below,  please record  the volume of  dopant:  gases
     that are used on a yearly basis.
                                     Volume Used
          Gas                          (n3/yr)

          Arsine	

          Diborane                   	
          Phosphine    '            •  	
          Silane	

     12-month period for which data is reported:-
                            Cone er.tr at ionl
                           (Volume Percent)
5.   Please indicate which photo lithographic process is used:

                Positive' photoresist

           	 Negative photoresist
6.   How many hours per year does the photoresist equipment operate;

                Hrs.
     For  each  volume  reported,  indicate  what  percent  of  that  volume  is
     actually  the gas  of  concern.   For  example.  100  cubic meters  of  a  gas
     mixture" containing 50  percent  (by  volume)  arsine  was  used  one year.
     Record  100 under the  volume  used column for  arsine and 50 percent under.
     the concentration  column.

-------
                              COUNTY HEALTH DEPARTMENT

                     SURFACE COATING MANUFACTURING SURVEY
     Please provide as an  attachment:,  a block diagram of  the  surface coating
     manufacturing  process  showing materials  storage equipment,  feed  equip-
     ment, mixing tanks, and all air  pollution control  devices.   This diagram
     should show all 'of the materials entering and leaving the system.

     Please record  the 19-T production  rate  for  this  facility  in  the  space
     provided below:
     Paint:

     Varnish:
                   Ibs

                     Ibs
        Bodying Oil:

        Oleoreains:

        Alkyd:  	

        Acrylic:  	

     Ink*
                            Ibs
                           Ibs
                      Ibs

                        Ibs
                Ibs
2.'   Please complete Table 1 for each pigment used by the facility.

3.   Please complete  Table  2  separately  for  each  product  produced  at  your
     facility.   Make multiple copies of this table as necessary.

4.   Please complete  Table 3  for  each  solvent  used  in  tank  cleaning  oper-
     ations.

5.   Where  available,  please  submit  material  safety  data  sheets   for  the
     pigments  and solvents identified in Tables 1 through 3.
6.
Describe tank cleaning procedures:

-------
7.   List the quantity of waste generated from  tank cleaning and  describe  the
     treatment/disposal practices  for this waste:		
8,   Please provide  the  following information for each air  pollution  control
     device 'used sc the facility:
Production
                              Pollutant
Ooeration     Control Device  Controlled  Efficiency     Basis for Efficiency'
     Efficiencies should be reported in terms of weight percent removal of the
     pollutant controlled.

     Describe.the  basis  for estimating efficiency  (i.e..  source  test, vendor
     guaranty, etc.).     '                           .    .

-------
                            TABLE 1.   PIGMENT USE INFORMATION
                                        PIGMENT USE2                                 3
PIGMENT NAME    PIGMENT .COMPOSITION1      L3S/YR        FUGITIVE DUST EMISSION LOSSES
 1  By weight percent,  list the major constituents of the pigment.

 2  List the annual pigment use for the facility.

 3  As a percentage of the total pigment use. estimate fugitive dust emission losses  that
    occur during the handling of the dry pigment.

-------
















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-------
                     TABLE 3.   CLEANING SOLVENT USE INFORMATION
  SOLVENT NAME
SOLVENT COMPOSITION
SOLVENT USE"
  LBS/YEAR
  SOLVENT
EVAPORATIVE
LOSSES (%)J
By weight percent, list the major constituents of the solvent.

List the annual solvent use for the facility.

As a percentage of the total solvent use. estimate solvent losses  due  to  evaporation

-------
                               COUNTY HEALTH DEPARTMENT

                  ETH7LENE OXIDE STERILIZATION QUESTIONNAIRE

                                    PRESAGE
Purpose

     The purpose  of this questionnaire is  to gather information  that  can be
used to  estimate  air emissions of  ethylene  oxide from hospital sterilisation
and surgical equipment mnaufacturing activities.

General Instructions

     In order to  accurately  estimate  ethylene oxide emissions from hospitals,
we  need  information  relating  to  the entire  hospital (questions  1  and 2) as
well as specific information on each ethylene- oxide sterilizer used 
-------
                              COUNTY HEALTH DEPARTMENT
                  ETHILENE OXIDE STERILIZATION QUESTIONNAIRE
1-    Is ethylene oxide used
                            as a
                                  sterilant ac your facility?
                                                                  iss
     If ethylene oxide is not used,  please answer question 1 (a) and return
     this questionnaire.   If ethylene oxide is  used,  please answer the
     remaining  questions.
       (a).  "Are  the materials  from
                                     your facility sterilized vich ethvieru
            oxide at a contract sterilization  facility?
                                                                 les
No
            If yes, please name  the facility which does your  ethyler.e  oxide
            s~erilization:
2.    If this is a hospital,  how many beds are there i
     imately)?   _ .                   '
                                                   in your hospital (approx-
   As  compared  to other hospitals, do any conditions  exist  at your hosp:
   which  may _ lead to  a  higher  or  lower  than  average ' use  of  material,;
   sterilized  with  ethylene  oxide   (such  as  an above  average  amount  of
   surgery)?
          Yes
                     No
   If yes,  please explain:

-------
If more  than  one ethylene oxide steriliser  is  used at your  facility,  please
make a separate copy of the remaining questions for each sterilizer used.
3.   Sterilizer number:
                  type:
                               (1. 2. 3...)
                               (table—coo or built-in)
4.   Sterilizer manufacturer and model:
5.
6.
7.
8.
Sterilizer volume:
                                             Cubic feet:
Average number of sterilization cycles per day (approximate):  	
Type of sterilant gas mixture used:
                 12% ethylene oxide and 88% freon-12 by weight
     	  100% ethylene oxide
                 10% ethylene oxide and. 90% carbon dioxide by weight  .
     • -.         . other.  Please indicate the •sterilant gas mixture used:
Size of container seerilant gas is received in:
     	•   70 Ib net weight cylinder
     	  75 Ib net weight cylinder
     	  160 Ib net weight cylinder
     	  67 gram cartridge (3M Sterigas* 2-67)
     	  100 gram cartridge (3M Sterigas« 4-100)
     	  134 gram cartridge (3M Sterigas* 4-134)
                 other.  Please indicate size:

-------
9.   Please indicate the number of sterilant containers used:

          monthly:  	•  and

         annually:  	•

10.  Is  a  non-recirculating water-sealed  pump used  to evacuate  the  steril-
     ization chamber?_

                (yes/no)
     If no. please describe the type of pump used for sterilization chamber
     evacuation:            .	
11.  Are any  emission  control  devices  used to reduce ethyler.e oxide emissions
     to the outdoor air?
                 (yes/no)
     If yes, please indicate the type and efficiency of control:

          	 scrubber

                     catalytic  filter •    •

                     carbon adsorption columns

                     other.  Please  describe  the  control  device  used:
                      Efficiencyl:

            Basis  for Efficiency!:
 1     Efficiencies  should  be  expressed  on a weight removal basis.

 2     Describe  the  basis  for  the efficiency estimate (i.e.. source test, vendor
      guaranty,  etc.).

-------
EXAMPLE 4 - INDUSTRY SPECIFIC QUESTIONNAIRE

-------
          •   POLLUTION CONTROL AGENCY
         DIVISION OF AIR QUALITY

AIR POLLUTANT EMISSIONS INVENTORY REPORT '
         FOR CALENDAR YEAR 1984

DIRECTIONS:  PLEASE TYPE OR PRINT ALL INFORMATION REQUESTED.

GENERAL INFORMATION

Facility Name         	
Faci1ity Location
                      (street)
                      (city)
                      (state)
                               (county)
Facility Mai ling
    Address
Telephone Number
Property Area
Number of Employees
Principal Product
or Service Provided
(street or box number)
                      (city)
                      (state)
                               (zip code)
_ •	.  	 acres  (report to nearest tenth)
Name of Individual
Responsible for
Concent of Forms
Return' to:
                      (signature of company officer and title)
PQ-00254-06

-------
                    POLLUTION CONTROL AGENCY: DIVISION OF AIR  QUALITY
                      ANNUAL STACK  OPERATING INFORMATION

I.   COMPLETE THE FOLLOWING FOR EACH  STACK OR EMISSION EXHAUST VENT:

     1.   Company stack ID number -

     2.   Stack height _ ____ feet  above ground  level

     3.   Stack exit  diameter ___ •_ feet,  inside diameter

     4.   Stack gas exit temperature ____  degrees  Fahrenheit,  rated  load

     5.   Stack gas flow rate _______ ACFM,  rated  load

     6'.   Stack gas exit velocity _____ feet/minute  at exit, rated  load


     7.   Northing  UTM  Coordinates _ . ---- ' -fn lifter f*
           ullH^o^pSrcarmfplf-n^rcthe^lrJrelse  leave blank.


     8.   Emissions and controls for this stack:
              Method
EQUIPMENT      Used to

 ' fKEK? BBSS,
Estimated
  Annual
                                                                 Method
                                                                 Used L
 Particulates
   (Total)


 Particulates
   (less  than 10.microns)
 Sulfur
   oxides
 Nitrogen
   oxides
 Carbon
   monoxide
 Volatile
   Organic
   Compounds
 Lead
  (Other)

  PQ-00254-06

-------
                  POLLUTION CONTROL AGENCY:  DIVISION OF AIR QUALITY
                     ANNUAL BOILER OPERATION INFORMATION

II.   COMPLETE THE FOLLOWING FOR EACH BOILER; TURBINE; OR DIESEL ENGINE:

       T.   Company boiler ID number 	

           Type of combustion unit:'  	Boiler 	Diesel Engine 	Turbine
       10
       11
       12.
           Stack number (Section I) this boiler vents through 	

           Average actual working schedule:
           . '	hours/day; 	 days/week;	weeks/year

       5.  Average boiler capacity factor for year     .:
              	 percent of total capacity when operating

       6   Percent annual BTU consumption of fuel (should total 100%)
             	 Dec.'   - Feb.'  ;  	 Mar.'   - May  '   ;
             	Jun.1   -Aug.'  ;  	Sep.'  .-Nov.1

       7.  Rated design capacity  (give both):
             	;	million BTU/hour heat input
             	'	  1000  Ibs steam/hour output

       8.  Percentage of fuel used for space heating 	.—
           Primary type of fuel
             .Total amount burned/year and units
             .Firing method
             .Usual firing rate and units 	
             .Maximum firing rate and units 	
             .Percent sulfur content 	.	
             .Percent .ash con-tent .....	.	  •
             .Heat content	BTU/,
                                           (please specify)
              .Percent seasonal fuel usage (should total  100%):
                	 Dec.1   - Feb-1   ;  	 Mar.'    - May
                	 Jun  '   - Aug.'   ;  	 Sep.1    - Nov.1
Secondary type of fuel
              .Total amount burned/year and units
              .Firing method
                                                       (please  specify)
  .Usual firing rate and units 	
  .Maximum firing rate and units 	
  .Percent sulfur content 	'._	
  .Percent ash content 	.	
  .Heat content	BTU/	,r  -
  .Percent seasonal fuel usage (should total 100%):
     	Dec.'    - Feb.'  ;	Mar."   - May  '
     	Jun.'    - Aug.'  ,	Sep.1   - Nov.1

If you use more than two types of fuel, please check here 	
  and list the corresponding information for each additional
  fuel on the back of this page.

Are you burning waste materials (used oi1,solvents,sol ids,etc.)?
  	 Yes   	 No (Check One)   If so, itemize and 'indicate
  quantities (with units) of waste materials being  burned:
 PQ-00254-06"

-------
                               POLLUTION CONTROL AGENCY
                          DIVISION OF AIR QUALITY
                    ANNUAL PROCESS OPERATING INFORMATION
III.   COMPLETE THE FOLLOWING FOR EACH PROCESS:

         1.  Company process ID number 	_
         2.  Stack number this process vents through
               (from Section I)

         3.  Type of process causing these emissions
         4.  Type of equipment used during this process 	

         5.  Average actual working schedule:
               	 __ hours/day;  	 days/week;  	 weeks/year

         6   Percent annual throughput  (should total 100%):
                     Dec.'   -Feb.1   ;  .	Mar.'   -May   -
               ~~Jun.'   -Aug.1   ;	Sep.1   -Nov.'

         7.  Type of raw materials used	.	
         8.  Quantity of  raw materials  used/year  (specify  units)
          9.   Quantity  of  products  produced/year  (specify  units)
         10.   Process  auxiliary fuels  (if  present):
         11,
                Type of  process- auxiliary fuel:
                Total  amount  burned/year: 	
                Firing method:
                Usual  firing rate and units:  	
                Maximum firing rate and units:  —
                Percent sulfur content:  	.	
                Percent ash content:    - _i 	•—
                Heat content:	BTU/.
                                             (please specify)
  Percent seasonal  fuel  usage (should total  100%):
          Dec.1    -Feb.1  -;   	Mar.1    -May
    HZJun.1    -Aug.'«;	Sep.'    -Nov.'

If more than one type of auxiliary fuel is used, list the
  corresponding information  for the additional fuels used
  on the'back of this page.
 PQ-00254-06

-------
                               POLLUTION CONTROL AGENCY
                          DIVISION OF AIR QUALITY
                  ANNUAL INCINERATOR OPERATING INFORMATION
IV.  COMPLETE THE FOLLOWING FOR EACH INCINERATOR:

       1.  Company incinerator ID number 	
       6,

       7.

       8.

       Q


      10.
           Manufacturer's name and model number
Stack number this incinerator vents through _
  (from Section I)

Average actual working schedule:
  __ hours/day;  _ days/week;  __ weeks/year

Percent annua1 throughput (should total
  __ Dec. '    - Feb. '   ;  __ Mar. '
  __ Jun.1    -Aug.'   ';  __ Sep.1
                                                     - May  '
                                                     -Nov.1
Rated design capacit'y
Type(s) of waste burned (I,II,..

Annual quantity of waste burned
Number of.primary, burners
  at an input of 	
   Ibs/hour

   ...VI) _
               tons
BTU/hour/burner
Number of secondary burners
  at an input of 	
                                         BTU/hour/burner
      11.  Type-of auxiliary fuel used
             Total amount burned/year and units
             Firing method
             Usual firing rate and units 	
             Maximum firing.-rate and unjts 	
             Sulfur content of this fuel 	.	 percent
             Ash content of this fuel 	.	 percent
             Heat content
                              BTU/
             Percent seasonal fuel usage (should total
               	 Dec.' '  - Feb.'   ;   	 Mar.'   - May
               	 	 Jun. '   - Aug. '   ;	Sep. '   - Nov.

      12.  Are you burning any other  waste material?
              .(please specify)
             If so, itemize and indicate quantities (with units) of
             other waste materials being burned:
PQ-00254-06

-------
                               POLLUTION CONTROL AGENCY
                          DIVISION OF AIR .QUALITY
                    ANNUAL ASPHALT OPERATION INFORMATION
II.  COMPLETE THE FOLLOWING FOR EACH HOT MIX ASPHALT UNIT:

       1.  Company asphalt unit ID number 	
       2.  Stack number this asphalt unit vents through
             (from previous page, Section I)
       3.  Type and manufacturer of this unit
       4.


       5.


       6.
Date manufactured
  Date purchased by present owner
Average actual working schedule:
  	 hours/day; 	 days/week; 	 weeks/year

Percent annual throuahput (should total  100%):
  	Dec. "   - Feb. '    ;	Mar. '   - May  '
        Jun.1    -Aug.1    ;  	Sep.'-  -Nov.'
       7.  Type and amount of raw materials used
       8.  Amount of hot mix asphalt produced during 1984

       9.  Is this a conventional 'or drum mix un'it? 	
      10.


      11.
      12.
                                                            tons
Do you do any recycling? 	
  material  is from-recycled asphalt? .

Type of fuel (or waste oil) burned 	
  .Total amount burned/year and units
  .Percent  sulfur content 	.	
  .Percent  ash content    	 	.	
  .Heat content	BTU/__
  .Usual firing rate and units
If so, how much of your raw
	 percent
                                                          (please  specify)
   .Maximum firing rate and units 	;	
   .Percent seasonal fuel usage  (.should total  100%):
     	Dec.''  - Feb.'" ';	Mar. '    - May  '
     	Jun.'   - Aug.'   ;	Sep.'    - Nov. '

If you use more  than one type of fuel, please check  here 	
  and list the  correspondirrg  information  for  each additional
  fuel on the back of this page.
PQ-00254-06

-------
                                POLLUTION CONTROL AGENCY
                           DIVISION OF AIR QUALITY
                 ANNUAL GRAIN ELEVATOR OPERATION INFORMATION
A.
                                                          Export
COMPLETE THE FOLLOWING FOR EACH ELEVATOR:

1.  Type of elevator:  	 Country  	 Terminal  _

      Storage capacity of elevator bin(s) 	
      Average actual working schedule:
        	 hours/day;  	 days/week;  	 weeks/year
      Percent annual throughput (should total 1QO%):
        	Dec,1   -Feb.1  ;	Mar.1   -May1  ';
        	Jun.1 -'• - Aug.1  ,;	Sep.1 ' - Nov.'

2.  Amount of each grain (or grain product) received (tons/year)
          Corn
          Soybeans
          Oats
          Soybean Meal
                                   Wheat
                                   Barley
                                   Sunflowers
                                   Other (specify)
    3.  Total grain handled  (tons/year):
          Received by:
                    Truck
                    Rail
                    Barge
          Headhouse 	
          Tripper   	
          Removal  from  bin
          Cleaned   	
          Dried     _
          Shipped  by:
                    Truck
                    Rail
                    Barge
     4.   Emissions  and  controls:
  Type  of     Elevator
  Control     Process
 Equipment   Controlled
                     Exhaust
                     Vent Ht             Method
                      (Feet   Control    Used  to
                      Above  Efficiency Determine
 Estimated
  Annual     Method
Particulate  Used to
 Emissions  Determine
                     Ground)  (Percent)   Efficiency   (Tons/Year)  Emissions
 Continue list  on back of page  if  necessary.
 PQ-00254-06

-------
                                POLLUTION CONTROL AGENCY
                           DIVISION OF AIR QUALITY
                   ANNUAL GRAIN MILL OPERATION INFORMATION
B.  COMPLETE THE FOLLOWING FOR EACH MILL/BREWERY:
    1.  Type of mi 11/brewery
          Storage capacity of mill bin(s) 	___
          Average actual working schedule:.
            	 hours/day;  	 days/week:  	 weeks/year
          Percent annual throughput (should total 100%):
               _ Dec.1   - Feb.'  ;	. Mar."  - May  '
                  Jun.1   -Aug.1'  ;  	Sep.1'  -Nov.1
    2.  Total grain processed:

          Feed manufactured:  Bagged
                              Bulk shipped
                                tons
                                tons
          Soybean processing: Oil  	
            (specify units)    Meal	

          Wheat milled:   Flour  bagged
                          Flour  bulk  shipped
                          Mill feed shipped
           Other mi lied:      Bagged
           (please  specify)   Bulk  shipped
                             Mill  feed  shipped

    •3.   Emissions  and  controls:
                                      tons
                                      tons
                                      tons

                                      tons
                                      tons
                                      tons
  Type of     Mi 11 ing
  Control     Process
 Equipment  Controlled
Exhaust
Vent Ht             Method
 (Feet   Control    Used to
 Above  Efficiency Determine
 Estimated
  Annual     Method
Particulate  Used to-
 Emissions  Determine
Ground) (Percent)  Efficiency  (Tons/Year) Emissions
 Continue list on back of page if necessary.

 PQ-00254-06

-------
                     POLLUTION CONTROL AGENCY:  DIVISION OF AIR QUALITY
                         PETROLEUM PRODUCT STORAGE TANKS
1.
Tank ID number 	_
.Tank type _____	_—r	
 Average actual working schedule:
   24 hours/day;  7 days/week;  	weeks/year
.Product stored 	_		
   Reid vapor pressure 	 PSI
   Average true vapor pressure 	 PSI
.Tank capacity  (specify units) ^^	_
.Tank throughput  (specify units)              	
 Percent annual throughput  (should  tota
         Dec.'    -  Feb.'   ,	Mar.(
   ~ _ Jun.1. •  -  Aug."   ;  —.  —  SeP-
 Type of vapor  control equipment:
    Control efficiency	.__ percent
     How was  this efficiency  determined
                                              100%):
                                                -  May
                                              '  -  Nov.
        Estimated  annual  VOC  emissions  _.—-
          How  were these  emissions  determined
                                         	..	 tons/year
                                                                after  controls
 2.
 Tank ID number _____	
 .Tank type ____	.	-——
  Average actual working schedule
    24 hours/day;  7 days/week;
 .Product stored    .._	__
    Reid vapor pressure 	 PSI
                                        	 weeks/year
        Average true vapor pressure .	PSI
     .Tank capacity (specify units) _	_
     .Tank-throughput (specify units)
      Percent'annual throughput (should tota.
           __Dec.'   -Feb.1'. ;	Mar.(
        	Oun.1   - Aug.1  :	Sep.
      Type of vapor control equipment:
        Control efficiency 	.__ percent
          How was  this efficiency determined 	—
        Estimated  annual  YOC emissions __	.__  tons/year
         -.'How were  these  emissions determined .	_	
                                          100%):
                                          - - May
                                           . - Nov.
                                                             after  controls
 3.
  Tank  ID  number	
  .Tank  type    ...	—	-
  Average actual  working  schedule:
     24  hours/day;   7 days/week;   	 weeks/year
  .Product stored  	__	
     Reid  vapor  pressure 	 PSi
     Average  true  vapor  pressure  	 PSI
  .Tank capacity  (specify  units)
                                               100%):
                                                 - May
                                                 - Nov.
  .Tank throughput (specify units)
  .Percent annual  throughput (should tota
        _ Dec.'  -  - Feb.'.  ;   	 Mar.
     	Jun.1    -Aug.1.  ;	Sep.1
  .Type of vapor control equipment:
     Control efficiency 	.— percent
       How was this efficiency determined	.	
     Estimated annual VOC emissions 		•__ tons/year
       How were these emissions determined .	
                                                                 after controls
  PQ-00254-06

-------
                    POLLUTION CONTROL AGENCY: DIVISION OF AIR QUALITY
                      PETROLEUM PRODUCT TRANSFER STATIONS

COMPLETE THE APPROPRIATE SECTION FOR EACH"TRANSFER  STATION WITHIN  YOUR FACILITY
PHOTOCOPY ADDITIONAL PAGES IF NECESSARY.
A.  Tank truck/car transfer  station  ID _^	

    1.  Loading:

         Averaqe  actual  working  schedule:
        .average  hours/(jay;  _adays/week;	weeks/year
         .Method  of  loading (submerged or splash)
         .Type  of  product 	

         .Quantity/year transferred
                    1000 gallons
         .Vapor control equipment:
            Control  efficiency	.__ percent
              How was this efficiency determined 	—
            Estimated annual VOC emissions _ _ _	•_ tons/year
              How were these emissions determined 	_	
 8.  Barge/ship transfer station ID .	

     1.  Loading:

         .Average actual working schedule:
         .   __.	 hours/day; 	'days/week;
	'weeks/year
         .Type of product 	

         .Quantity/year transferred
                     1000  gallons
          .Vapor control  equipment:
            Control  efficiency 	-— percent
              How was  this  efficiency  determined  _	.	.—_
            Estimated  annual  VOC  emissions	-_ tons/year
              How were these  emissions determined 	:	
      2.   Ballasting:

           Averaqe actual  working schedule:
             _ _ hours/day;  _ days/week;	weeks/year
          .Type of product	

          .Quantity/year transferred __	
             (total cargo capacity)

          .Vapor control equipment:
             Control efficiency 	.— percent
               How was this efficiency determined
                     1000 gallons
               MOW W35 LOIS CII IUICIIV.JT vis.t.w. in •••».- 	_	
             Estimated annual VOC emissions _	._ tons/year
               How were these emissions determined 	.	
  PQ-00254-06

-------
                                APPENDIX H
                    EXAMPLE PRELIMINARY AND FOLLOW-UP
                              QUESTIONNAIRES


     The following sample preliminary and follow-up  questionnaires  are
examples only and are provided as a resource of information.   They  are
not to be reused and are not endorsed or recommended for  use,  nor do  they
represent flawless examples.  Each agency should tailor questionnaires  to
the specific needs of the area.
                                   H-l

-------
EXAMPLE 1 - PART I AND PART  II OF AN  INVENTORY QUESTIONNAIRE

-------
            Potentially Toxic Chemicals (as identified by the U.S. EPA)
                                        (*)  chemical under study by
  Acetaldehyde.
  Acrolein
  Acrylonitrile

  Allyl  Chloride
  Arsenic  (*)
  Asbestos

  Benzene  (*)
  Benzyl Chloride
  Beryllium

  Cadmium
  Carbon Tetrachloride
  Chlorobenzene
   We
purchase
  this
chemical

   C 3
   C 3
   C 3

   C 3
   C 3
   c r

   C 3
   C 3
   C. 3

   C 3
   [ 3
   C  3
 •Chlorofludrocarbon (FC-113)  [ 3
 Chloroform  .                 [ ]
 Chloroprene    '              [ ]
 Chrcmium
 Coke
 o-,m-,p-Cresol

 Dichloromethane
 p-Dichlo'robenzene
 Dialkyl Nitrosaminea (*)

 Dimethyl Nitrosamine
 1 , ^-Dioxane
 Dioxin


 Spichlorohydrin
 Sthylene Dibromide (»)
- Ethyl ene Dichloride

 Ethyl ene Qride
 Formaldehyde
 Hexachlorccyclopentadiene
  L 3
  C 3

  C 3
  E 3
  C 3

  [ 3
  C 3
  E 3

  C 3
  C 3
  C 3

  C  3
  [  3
  C  3
                                          We         We         This      This chemical
                                        package   manufacture  chemical   nay be present,
                                         this       this      aay be an      in our
                                       chemical   chemical   intermediate  incinerator
 E 3
 C 3
 E 3

 C 3
 C 3
 C 3

 C 3
 C 3
 E 3

 E 3
 [ 3
 C 3

 E 3
 £  3
 E  3

 C  3
 C  3
 C  3

 C  3
 C  3
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 E  3
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 £']
 C  3

C  3
C  3
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 r 3
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 [ 3
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 C  3
 C  3
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 [  3

 [ 3
C 3
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 C 3
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 C 3
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 C ]

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•C  ]
 C  3
 C  3

 C  3
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 L  ]

 C 3
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C 3
C 3
C ]
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 C  ]
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 i  3
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 C  3
 i  ]
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 C  3
 L  3
 [  j

 C  3
 C  3
 C  3

[  3
C  3
C  3

-------
Plant Name
Address
City

Attn:                              *t-  planfc *

Gentlemen:

Thank  'you for responding to Part I of our chemical usage   survey,   in
Part I of the survey,  you indicated that you used certain   sucstancs,
af your facility.   The purpose of Part II is to quantify  this  usage
This  survey is authorized by the State Health and Safety Coae Part  2
of Division 26, Chapter 3-5 (

Please review the attached form.   The values in the  column   "Quantity
Purchased"  are  based on permit applications and annual updates   su.-
mitted by you to the District.

1   Circle ail correct values.  Replace all. out-of-date,  incorrect  or
    blank  values  with the'correct quantity  for Calendar   j.ear   «,c~- <
    Values should be correct to within 100 Ib/yr, or  10%, wnicnever  is
    larger.

2   If  you obtain a substance as a component of a  mixture,   indicate
    the  annual quantity  of the mixture obtained,  as  well  as the per-
    cent of the substance contained in the mixture.

3   If  the- substance is contained in products,  please  indicate   the
    .quantity and concentration of the substance  in  your products.

i|.  Please indicate  the concentration and quantities  of each substance.
    incinerated.

This   survey should  be-returned by            ...  Your  information^
exceot for trade secrets,  may be released for  public inspection.    ,-
you consider any information to be a  trade secret,  laoel  it  clearly a*
"Trade Secret".
 If  you  have  any  questions  or  comments,  please  call
                                    Very  truly yours,
                               by:

-------
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     4J. U   3
       v  t;
                                                                                      IQ  4-1 C
                                                                                      £   TJ -*
                                                                                           U
                                                                                          — o •
                                                                                       s -a  ui
                                                                                      p  e -<
                                                                                                                UJ
                                                                                                                
                                                                                                                                                               s_-
                                                                                                                                                            •f-  a
                                                                                                                                                                - -t-J
                                                                                                                                                            "a  (O1.
                                                                                                                                                             c < —
                                                                                                                                                            •i-  ai.
                                                                                                                                                              a  ait
                                                                                                                                                              
                                                                           -l->  U5
                                                                           3
                                                                           C..-W
                                                                           e  o
                                                                           o •<—
                                                                           u  s-
                                                                               •1-1
                                                                           4)  Ul

                                                                           P  5

-------
EXAMPLE 2 - A QUALITATIVE AND QUANTITATIVE QUESTIONNAIRE

-------
                                                            Return Date:
                                                            Mar. 28. 1986
Chemical
fihstract finnua! Ualues (Vear 19 — )
Service
Number
(CflS)3 Haae
75-07-0 Acslaidshyds
107-13-1 Acryionitrils
71-43-2 esrcrsr^s
56-23-3 Carton Tetrschloride
67-66-3 Chloroform
1319-77-3 Crasals
95-50-1 o-Qichlorobenzsne
123-91-1 Oioxane
ICo-S'S-a Eoichiorohydrin
106-93-4 Ethylana Oibrotr.ide
107-06-2 Elhylene Oichloride
75-2 1 -o Ethviane Oxida
30-00-0 Forrnaliiahyde
77-M7—4 Haxacnicroc/c'opaniacisne
7 1 -55-6' r.atfiyi Chloraforrn
75-09-2 MaLhylana Chloride
1335-36-3 ?C3'3
127-1S— 4 Fsrchloroathylens
*C2-vw!-'? Phanole -
73-35-9 Propyisna Cxida
1 i 0-56-1 Pyridins
10C--42-3 Slyrane
105-3S-3 Tolusne
79-0 1 -6 Trichlcroethytena
75- ; 3- 1 1,1 .2-Trictiloro- 1 .2.2-trifiuoroeLhan8
7Q-OC-3 1.1 ,2-Trichioroslhana
73-3-3-M Viny!;dsne Chloride
1330-20-7 Xylenes

Used*
Rftount Units































Eaiss ions
F-Ttount Units



i
t























































!








i











1
!




            I certify that the information given above is correct.
            1 certify that none of the above are used9 (see cover letter).
   Signature
Official Title
Date.
Phone
Stata Form 20237
03/0-3/36
S£H6i-257

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Mr. NAME
COMPANY
ADDRESS
CITY, IN 46060
Dear Mr.  (NAME)
The Office of Air Management  (OAM) is continuing  to  conduct  a  survey
initiated in 1986 to help determine whether the impact 'from  certain
air toxic emissions is sufficient to cause a health  risk. The
information obtained from your company has been used to  initially
estimate the impacts on the air quality and now additional data  is
needed.

According to our records,               '    is routinely' emitted inco
the atmosphere from your facility. We have reviewed  the  data in our
files and find we need additional information in  order to help, us
estimate the potential impact from this compound. Please complete the
enclosed form and return-it to the OAM within thirty days. Please
include a plot plan showing all building locations,  all points of
emissions, stack heights, plant fence and property lines and location
and distance to the nearest residences.

             13-1-1-4(3)(3)  permits the State to  request this type of
information. Confidential data will be handled in accordance witih
established legal procedures  (320 IAC 6-1-1).

Please return questionnaire to:
If you have any questions or problems in completing the
questionnaire, please contact the person at either the address or
telephone number above. Your cooperation is appreciated.

                                        Sincerely,

-------
                     INSTRUCTIONS Jfrpr
 1 .   Company name and  address .

 2.   National Emissions Data System  (NEDS)  identification  number .

 3.   Chemical or compound name and Chemical Abstract Number  (CAS) .

 4 .   Designate year of emissions data, which should be the most recent
     available.

 5 .   Process Description - Submit a separate response for  all the
     emissions from each point and fugitive source or sources that
     pretain to this process that apply to' questions 9 through 21.
     Include manufacturer and any applicable number. Use quescion 21
     to quantify and describe emissions not covered in questions 9
     through 20 .  Show and identify each source on the plot plan

 6.   Operating schedule for process in which compound is used.

 7.   Estimate  the  amount of  compound  handled,  used,  processed or
     produced in  Lbs/Hour  and Tons/Year.

 8.   Submit  a  legible  plot plan  which shows  all emission  sources,
     building height and dimensions,  all other -buildings with their
     heights and  dimensions,  plant fence and property lines,  distances
     and location of nearest residences, a scale and an arrow showing
     north.

 9-11.    Indicate building height,  width and length  where emission
   .  source  is located  (Include all  other buildings with dimension
     information  on the plot plan.)              •             •

 12-15.   Stack or exhaust vent parameters. Stack height'- total
     distance  from ground  to top of stack.  If emissions are exhausted
     through a roof vent then complete:  vent height,  diameter or
    . dimensions if not round,  temperature (room)  and indicate exit
     volume.  Please describe how stack velocity or temperature varies
     with operation rate.

 16.  Estimate  actual emissions  in Tons/Year  and Lfas/Hour.

 17.  Basis of  emission estimate:  test  data,  emission factors, material
     balance,  etc.

 13 .  Do  not  list  the efficiency  of the control device  unless  it  is
     effective  for  the listed compound.

 19.  List  the device or methods  employed to  reduce emissions  of  the
     compound if applicable .

 20.   Fugitive  emissions occur from pumps, compressors, pressure
     relief devices, sampling connection  systems,  open  ended  valves  or
     lines, valves,  flanges and other  connectors,  product accumulator
     vessels, control devices or  systems  outside the building. Please
     list  number of  each.

21.  Quantify and  describe  any other emissions.

*    Fugitive sources,  as  in 20, may  be listed on one  data sheet
     if they are together.

-------
                              rOMPOTTND
                            GENERAL INFORMATION

1. COMPANY NAME AND ADORES S :    2. NEDS  ID:       3.  NAME OF COMPOUND and CAS*:
4. YEAR FOR EMISSIONS DATA

5. PROCESS DESCRIPTION:
6. OPERATING SCHEDULE

7. AMOUNT HANDLED
   PROCESSED, PRODUCED
   OR GENERATED
 _,_ Hours/Day
  »

   Lbs/Hour
Days/Week

Tons/Year
                                                                   Weeks/Year
8. IDENTIFY AND LOCATE ALL  SOURCES  OF EMISSIONS ON A PLOT PLAN SHOWING THE
   BUILDING HEIGHT AND DIMENSIONS,  PLANT FENCE AND PROPERTY LINES, DISTANCE AND
   'LOCATION OF NEAREST RESIDENCES,  A SCALE AND. ARROW SHOWING NORTH..
NAME(PRINT OR TYPE)
OFFICIAL TITLE
                                                        DATE
                                                                          PHONE
SIGNATURE

-------
                                SOURCE EMISSTOM  DATA.

                  PROVIDE SEPARATE RESPONSE TOR  ITEMS  9 THROUGH 21
                      FOR EACH POINT AND/OR FUGITIVE SOURCE(S)
 SOURCE NUMBER OR NAME  (SHOW LOCATION ON PLOT PLAN)
 9.  BUILDING HEIGHT

 11.BUILDING WIDTH

 12.STACK HEIGHT
    (Above ground)

 14.EXIT GAS VELOCITY

 16.ACTUAL EMISSIONS
JTeet

 Feet
 Feet
_Feet/Minute

 Tons/Year
17.BASIS  FOR EMISSION ESTIMATE:
18.CONTROL EFFICIENCY    	Design %
10.BUILDING LENGTH



13.INSIDE  STACK DIA.


IS.EXIT  GAS  TEMP.

	Lba/Hour
                         Actual  %
Cc-
19.POINT OR FUGITIVE EMISSION CONTROL METHOD OR DEVICE:
20.FUGITIVE EMISSIONS;
   NUMBER OF COMPRESSORS  	,  PRESSURE RELIEF DEVICES
   CONNECTION SYSTEMS	,.  OPEN-ENDED VALVES OR LINES ~
   OTHER CONNECTORS	,  PRODUCT ACCUMULATOR VESSELS	,
   CONTROL DEVICES OR SYSTEMS	,  OTHERS (PLEASE DESCRIBE)
                             _, SAMPLING
                             ,  VALVE,FLANGES AND
21. QUANTIFY AND DESCRIBE  OTHER EMISSIONS NOT COVERED ABOVE:

-------
EXAMPLE 3 - A PRELIMINARY AND  FOLLOW-UP  QUESTIONNAIRE

-------
Dear Sir:   •

           The '            Department of Environmental Resources is developing an Air Toxics!
Inventory.  As a prelirainarv step in the development of the inventory, we are conducting a survey]
to.determine the presence and use of selected substances in '              Jour_as3istanc2  in w;:d
matter is required under Section 4 of the Air Pollution Control Act, P.L. 2U9, §a (35 P.S. ^uU-,;.|

           A survey form, instructions and a list of substances are attached to this letter.  Pleas?
complete the form aa indicated, using one block for each listed substance; or group of cornpouncs.
If you do not use, store or produce any of the listed substances,.please enter "NONE" m -the fun-
block and return the-form.              •

           If you have submitted similar information to another  governmental-agency, you  may
substitute a copy of that submittal for the completed Air Toxics Survey Form.

           Your response by -  -      ;    , will be appreciated. If you have any questions
concerning this matter or need assistance completing the forms, please  contact,
the address or telephone number above.

                                                 Sincerely,
Enclosures

-------
Instructions for completing the Air Toxics Survey form.

Section I.

     Make corrections to the pre-printed address label on page 1 of the forrp ^ lining cut
     incorrect information and inserting corrections in the blank space to the ngnt of the
     label.

    • Enter the SIC code for your facility in the space indicated.

Section II.  Complete one block for each compound or group of compounds from the attached iJ
           which you have or use.
Line I.
      CAS-Number: Enter the registration number assigned to the compound by the
      Chemical Abstract Service. This number will be used to identify those compounds
      present at your facility.

      Name:  Enter the name of the compound as indicated on the attached list or an
      acceptable synonym.  Do not use trade names or brand names.
Line 2.
      Mark the aporopriate block(s) to indicate whether the compound is used in a process or
      operation, stored (other than stock maintained to make up losses), manufacture^ or
      produced, occurs as a by-product of a process or operation, or is a component 01 a
      material used or produced at your facility.   •                    •
Line 3.
      Identify how the substance is or may be emitted into the atmosphere by marking out
      the items which do not apply. "Stack" includes any vent, duct or pipe througn wnicn
      the substance may be emitted to the atmosphere.
 Line
      Describe the type of equipment used to control or reduce emissions of the specinec
      substance.  If there is no control, enter "NONE."  Enter the percent efficiency 01 th«
     _ control equipment for the specified substance.
 Line 5.
      Enter the maximum rate in pounds per hour at which the specified substance could be
      emitted from this source if there were no emission controls.
 Line 6.
      Indicate the normal operating schedule of this source by marking out the items which
      do not apply.
 Line 7.
      Enter a description of the equipment, process or operation in which the substance is
      used, stored or produced. The description should be sufficiently specific that the
      equipment will be readily identifiable by both plant and Department of Environmental
      Resources personnel.

-------
                                     Air Toxics Survey Form
Section I.
                                                                             Page L of
                                          Corrections:
                address label
                                                          SIC
Section II.
   o  CAS Number 	-	-_

      Used '        Stored 	
                               Name
                     	  Manufactured 	   By-Product

Emissions:  (Fugitive/Stack)    (Controlled/Uncontrolled)

     Type of control:	,
   Ingredient
                                                                    Efficiency (%)
           Maximum hourly emission rate in pounds (uncontrolled):

     Operation: (Continuous/Periodic)   (Seasonal/Yearround)

           Description: 	;	,	•         	
   o  CAS Number	

      Used        Stored
                                Name
      		  Manufactured 	  By-Product

Emissions: (Fugitive/Stack)    (Controlled/Uncontrolled)

      Type of control:	
    Ingredient



Efficiency (%)
           Maximum hourly emission rate in pounds (uncontrolled):

      Operation:  (Continuous/Periodic)    (Seasonai/Yearround)

           Description:	;	
      Return to:. Bureau of Air Quality Control
                Division of Abatement and Compliance

-------
               Department of Environmental  Resources
            Bureau of Air Qual i ty  Control

     List of Substances  for  Air  Toxics  Inventory
CAS No.    Name of  compound/c!ass
0073-34-5
0107-06-2
1746-01-6
0092-67-1
'0075-07-0
0107-13-1
0107-05-1
  (group)
1332-21-4
0071-43-2
0050-32-3
  ( g r o u p D •
0117-31-7
  (group}
0056-23-5
  (group }
0067-66-3
  (group}
0075-0,9-2
0106-39-3
0100-4.1-4
0075-21-3
0050-00.-0
  ( g r oup 3' ,
  (group 3
 0071-55-S
 0030-62-5
  (group 3
 0093-95-3
 0087-86-5
 0127-18-4
 0108-95-2
 0075-56-9
 0 100-42-5
 0108-38-3
 0079-01-6
 0075-01-4
  1330-20-7
1 , 1 ,2,2-Te trachloroethane
1 ,2-01 chloroethane(Ethytene  Dichlo
2,3,7,8-Tetrachlorodibenzo-p-dioxi
4-Ami nob i pheny.l
AcetaIdehyde
Aery i on i t r i la
Ally! ChI or ide
Arsenic  4  Compounds
Asbes tos
Benzene
Senzo(a}Pyrena(BAP3
Beryllium  &  Compounds
Bi s(2-EthyIhexylDPhthalate
Cadmium  &  Compounds
Carbon  T«trach1oride
Chlorinated  benzenes
ChIo ro f o rm
Chromium & Compounds
 Dichlorom«thane(Methy lene Chi or ide
Epichlorohydr, in
 Ethyl Benzene
 E thy-.l ene Ox i d'e
 Forma Idehyde
 Manganese  i Compounds
 Me.rcury & Compounds
 Me thy I  Chloroform
 MethyI  Methacrylate
 Nickel  4 Compounds
 Ni trobenztne
"Pentachlorophenol
. Perch1oroe thyIene
 Pheno 1
 Propylene Oxide
 S ty r ene
 To Iue ne
 Trichloroet-hylene
 Vinyl Chloride
 Xy I ene

-------
  Facility 1.0. No.
  PEGS Source No.
  CAS #
                                 AIR TOXICS INVENTORY

                                       STORAGE
            Company Nan's	
            8AQC Permit No.	
            Air Toxics Substance
                  Liquid
  Tank  Capacity
 Pressure Relief Valve
         Yes	    No	

 Quarterly Throughputs (Gals>
  1st     2nd  •   3rd     4th
                             So 1 i d

_(Gals)      Bin  Capacity	(Lbs.)
           Quarterly Throughputs (Lbs.)
           1st    . 2nd     3rd     4th
 5 Air Toxics Substance
           % Air Toxics Substanca
                            EMISSION CONTROL EQUIPMENT
 Type
 Efficiency
X  (Air  Toxics  Substance  Removal)
 Stack Diameter
 Stack Height Above Grade

Potential Emissions (Max)
Actual Emissions

Method of Calculation
                              AIR  TOXICS  EMISSIONS
 (Ft)
 "(Fc)
Stack Temperature
Exhaust Volume
          (Lbs/Hr)
          (LDs/Hr)
	
JACFM)

 (Lbs/Yr)
 (Lbs/Yr)

-------
                                    OPERATION
 Facility 1.0. No.
 PEOS Source No.	~
 CAS f
            '  Company Name
              3AQC Permit No.	
              Air Toxics Substance
 Description of Process, Combustion Unit, Incinerator, etc.
 Air Toxics Source
[ngredient

8y-?roduct_
Fuel
                                                      Waste Disposal.
 Quarterly Tnroughputs  (Units_

   1st    2nd    '  3rd     4th
 Air Toxics  Substance  5
                  PPM
                            EMISSION  CONTROL  EQUIPMENT
 Type
.Efficiency
          (Air Toxics Substance Removal)
 Fugitive  Emissions     Yes
        No
                              AIR  TOXICS  EMISSIONS
Exhaust Volume         	
Temperature            	
5 Moisture             	
Stack Height Above Grade
Stack Diameter
Potential Emissions (Max)
Actual Emissions

Method of Calculation
             (ACFM)
           ".(Ft)

           I 

             (Lbs/Hr)
           " (Lbs/Hr)
             (Lbs/Yr)
             (Lbs/Yr)

-------
                                AIR  TOXICS  INVENTORY



                     OUTDOOR MATERIAL  STOCKPILING AND  TRANSFER
  Facility 1.0. No.



  PEDS Source No.	



  CAS *
 Quarterly Throughputs  (l'nits_	)



   1st    2nd     3rd    4th
              .Company  Name
             .. 8AQC Permit No.
              Air Toxic-s Substance
 Method of Transfer
 % Air Toxics Substance
               EMISSION CONTROL EQUIPMENT OR OTHER CONTROL MEASURES
 Type
 Efficiency
Potential Emissions (Max)



Actual Emissions
 AIR TOXICS EMISSIONS





	 (Lbs/Hr)	



     (Lbs/Hr)
(Lbs/Yr)



(Lbs/Yr)
Method of Calculation

-------

-------
                                APPENDIX I
                     TOXIC CHEMICAL RELEASE INVENTORY
                              REPORTING FORM
     The following USEPA Form must be completed by applicable sources by
July 1, 1988, as required by Section 313 Title III of the Superfund
Amendments and Reauthorization Act of 1986.  Please note that the format
of this form may change in future years.
                                   1-1

-------
(Important: Type or print; read instructions before completing form.)
                                                                                                 Approval Expires:.
                                                                                                                     01/91
                                                                                                                Page  1 of 5
                                    U.S. Environmental Protection Agency
                  TOXIC CHEMICAL RELEASE INVENTORY REPORTING FORM
        Section 313. Title 111 of The Superfund Amendments and Reauthorization Act of 1986
                                                                                                             EPA  FORM
                                                                                                                   R
              PART I.   FACILITY IDENTIFICATION INFORMATION
                                                                                                        (This spaca lor SPA use only.
 1.
      1.1  O&»« this noon contain trad* s*cr*t Information?
           |   "| Y*s (Answar 1.2)      |   [  No (Oo not answ*r 1.2)
                                                       1.2  li ml* a Mnltlzod copy?
                                                            n Y»    n  ^
                                                                                                 1.3  Raoortlng Year
2. CERTIFICATION  (Read and sign after completing ail sections.)
I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief,  the submitted information is ;.-.
and complete and that the amounts and values in this report are accurate based on reasonable estimates using data available to the preparars
of this report.                   	^^^^	^___	
Nam* and official tltla of ownar/oowator or senior manaoamant official
S!c.natur*
                                                                                    Oata slgnad
3. FACILITY IDENTIFICATION
3.1
3.3
3.4
3.5
3.fi
3.7
3.3
3.9
      Facility or.gstafillsnmant Nam*
      StrMC Aaarass
      City
      State
                                                   County
                                                    Zip Coo*
                                                      \   i   i   r
                                                                         i   i
     Tacnnical Contact
      PuSlic Contact
                                                                                    3.2
                                                                                          This report contains Information for: (cracK anal
                                                                                              I   j  An antlrs coverad facility.
                                                                                           a. i__j

                                                                                           jj  |   [  Psrt o« a covarad facility.
                                                                                    Talaonorm Number (includa araa coca)
                                                                                    Taiaonon* Numoar {Incluca area
       a. SIC Coda

        I    I   I
                   D.
                                     J_
             Latltuea
     Mln.   Sac.

I   I   I    '
 0*3-     Mln.    Sac.

I    I   I   »    I   I
      Oun 4 Sradstreat Numoor(s)
                                   I   I
                                          b.
     SPA le«m!f(catlon Numoar (RCHA I.D. No.)
      a.
          i   I   i   I   I   I    I
     NPOES P«rmlt Numbar(s)
      a.
                l   l   l   I'  »   I
                                               b.
                                               b.
                                                       ''''	I   I   !
                                                                                              Whara to send completed forms:

                                                                                               U.S. Envlronmantal Protactlon Agency
                                                                                               P.O. 3ox 7026S
                                                                                               Washington. OC 20Q24-02SS
                                                                                               Attn:  Toxic Ofiamioal Halaasa Invantory
      Nam* o* Racalvlng Straam(») or Watar 8ody(s)
       a.
3.10
       b.
       c.
3.11
       Underground Injection Wall Coda (U1C) Identification No.

         1   I    I   I   I    I ' I   I   I   I    I
4. PARENT COMPANY INFORMATION
4.1
4.2
Nam* of Psrant Company
Parant Company' s Dun & Bradstraat No.
	 1 l-f ' 1 "I-! ' 1 1
:'
 EPA Form 9350-1 (1-88)

-------
  (Important: Type or print; read  instructions before completing form.)
                                          EPA FORM R
                     PART II.   OFF-SITE LOCATIONS TO WHICH TOXIC
                        CHEMICALS ARE TRANSFERRED  IN WASTES
                                                                                                                  Page 2 of 5
                                                                                                                 "•*^«««"^"»«B«««^ 	
                                                                                                         (Thf* spac* for gpA u*« oniy.
   1. PUBLICLY OWNED TREATMENT WORKS fPOTW
   Facility Name                                   	
    reel Address
                                            County
                                            Zip
  2. OTHER OFF-SHE LOCATIONS - Number thesa locations 3«qu»ntlally on this and any .ddltlonal
       Other off-site location
                                                                                                        page of this form you usa
   EPA Identification Number (HCflA 10. No.)

  Facility Nama
                                        I   I   I   I   I   '   '   '
      : Address
                                            County
   Is location under control of reporting facility or parent company?  1    I I   1


I   I Other off-sita location

EPA Identification Numb«r (HCSA IO. No.)  I   ',   '.   !  '.
                                                         Yes   No
  =acility Name
 Street Address
  tata
                                           County
                                           Zip
                                                 1''
   Is location under control of reporting facility or parent company?


r— |
| _ I  Other off-site location


SPA Identification Number (RCHA IO. No. )
                                                             I   I
                                                        Yas
  :»clllty Name
                                                                .11'
 Itreet Address
City
 tale
                                          County
                                          Zip
    Is location under control of reporting facility or parent company?  I   I I    I




     Chock if additional pages of Part II are attached.
                                                       Ye«   No
EPA Form 9350-1(1-38)

-------
(Important: Type or print; read instructions before completing form.)
                                       EPA  FORM R

                      PART III. CHEMICAL SPECIFIC INFORMATION
                                                                                                           Page 3 of 5
                                                                                                      (This jqmca for SPA usa only.
 1. CHEMICAL IDENTITY
 1.1
 I	|  Trade Secret (Provide a generic name in 1.4 below. Attach substantiation form to this submission.)
 1.2
       CAS#
                                        -n
                                                  (Use leading zeros if CAS number does not fill space provided.)
 1.3
      Chemical or Chemical Category Nam*
 1.4
      Generic Chemical Nam* (Complete only If 1.1 Is cnecked.)
2.
MIXTURE COMPONENT IDENTITY (Do not complete this section if you have completed Section 1.)
Generic Chemical Name
Provided by Supplier (Limit the name to a maximum of 70 characters (e.g., numbers, letters, spaces, punctuation)).

3. ACTIVITIES AND USES OF THE CHEMICAL AT THE FACILITY (Checfc all that aooly.)
3.1
3.2
3.3
Manufacture:
Process:
Otherwise Used:
a.j (Produce b. j 1 Import c.j j For an-sita
L—J L_J ^ L_J use/processing
d'D dlstrfb^lon «• D As a fayP--°du« '• D As an lmpurity


a. As a reactant b. f 1 As a formulation c As an article
I — 1 1 — 1 component ' 1 — 1 component
d. | | Repackaging only
»•) 	 [processing aid b- 1 	 | As a manufacturing aid c.| [ Ancillary or other use
 4. MAXIMUM AMOUNT OF THE CHEMICAL ON SITE AT ANY TIME DURING THE CALENDAR YEAR
   I	I  (enter cade)
 5. RELEASES OF THE CHEMICAL TO THE ENVIRONMENT
                                                            A. Total Release
                                                           	(Ibs/yr)
 You may report releases of less than
 1,000 Ibs. by checking ranges under A.1.
 5.1 Fugitive or non-point air emissions
 5.2 Stack or point air emissions
                                       S.1a
                                       S.2a--
                                                        A..1
                                                  Reporting Ranges
                                                      1-499   500-999
  A.2
  enter
Estimate
                                                                                      B. Basis of
                                                                                         Estimate
                                                                                         (enter code)
                                                                                        S.1b
                    D
                                                                                        5.2b
5.3 Discharges to water    5.3.1  [   |

   (Enter tetter code from Part I
   Section 3.10 for streams(s).)
                            5.3.2


                            5.3.3
                                         5.3.13
                                                                                           5.3.1b
                                         5.3.2a
                                                                                           5.3.2b
                                         5.3.3a
                                                                                           5.3.3b
                                                                                              D
                                                                                                     C. % From StcrmwatI
                                                                                                      5.3.ic
                                                                                                          S.3.2c
                            5.3.3c
 5.4  Underground Injection
                                       S.4a
 5.5 Releases to land

                    (enter code)


                    (enter code)


                   I (enter code)
                                     5.5.1a
            5.5.1b
                                     5.5.2a
             3.5.2b  Q
                                     5.5.3a
                                                                                      5.5.3b
D
(Check If additional Information Is provided on Part IV—Supplemental Information.)
EPA Form 9350-1(1-38)

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EPA FORM n.Part III (Continued)
Page 4 of 5
S. TRANSFERS OF THE CHEMICAL IN WASTE TO OFF-SITE LOCATIONS
You may raoort transfers
a< \«s» ttian %.QOO \o». ov cnocxina
ranges under A. i . .
5.1 Discharge to POTV/
6.2 (Entar block number
from Part II, Section 2. ) ' 1
5.3 Othar off-«ita location I 	 1
(Entar block number
from Part It, Section 2. ) 1 	 1
5.4 Other off-slta location f— I
(Entar block numoer
from Part II, Section 2. ) ' 	 '
A. Total Transfers
(Ibs/vrt
A.1
Reporting flanges
0 • 1-499 500-999












A. 2
enter
Estimate




8. Basis of Estimate
(enter cocte/
S.lb I I
6.2b I 	 1
S.3b Q

S.4b j^]
I C. Type of Treatment/
Gtspasat fencer coca/

S.20 I

S.3c

S.4o
I 	 ( (Check If additional Information Is provided on Part IV-Supplemental Information)
3. OPTIONAL INFORMATION ON WASTE MINIMIZATION
(Indicate actions taken to reduce the amount of the chemical being released from the facility. See the Instructions for coded
items and an explanation of what information to include.)
A. Type of
modification
(enter code)



B. Quantity of the chemical In the wastestream
prior to treatment/disposal
Current Prior ( Or percent
reporting year ( change
year (Ibs/yr) (Ibs/yr) ,
'• \

C. Index



0. Reason for action
(enter code)



EPA Form 9350-1(1-88)

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 (Important:  Type or print; read instructions before completing form.)
                                         EPA FORM R

                         PART IV.  SUPPLEMENTAL INFORMATION

         Use this section If you need additional spaca for answers to questions In Parts I and III.
  Number or letter this Information sequentially from prior sections (e.g.. 0,£,  F. or 5.54, 5.55).
Page 5 of 5
                                                                                                (This soaca for S.=A >jsa oniv.
ADDITIONAL INFORMATION ON FACILITY IDENTIFICATION (Part 1 - Section 3)
3.5
3.7
3.3
3.9
3.10
— — SIC Coda
1 1 1
1 1 1
Dun i Bradstreal Nume«r(3)
1 1 - 1 I.I 1 - |
I L_ [
III-
EPA Identification Mum&or(s) RCHA I.O. No.)
1 1 1 1 1 1 1 I 1 1
NPOSS Permit
1 1 1
Numo«r(3)
III!
1

1 1 - 1 1 1 1 - I 1 1 I
1



Nam* of Rocaivlng Stream(s) or Watar Body(s)
•
1 1 1 ! 1 1 1 ! !

I I
1 1 1 1 I 1 1 1



	
ADDITIONAL INFORMATION ON RELEASES TO LAND ( Part III - Section 5.5)
Releases to Land
5.5 	
5.5
5.5
(enter coda)
(•nter cod*)
(enter cod*)

5.5 a
5.5 a
5.5 a
A. Total Release
(Ibs/yr)
A:I
Reporting Ranges
0 1— «99 500-399









A. 2
enter
Estimate



B. Basis of
Estimate
(enter code)
5.5 b Q
5.5 b | |
5.5 b Q
ADDITIONAL
INFORMATION ON OFF-SITE TRANSFER ( Part III
•
"•— Olscnarge '.o POTW
Other off-site location i 	 1
6. (Enter alocx number
	 from Part II. Section 2. ) 1 	 1
Otnar off-tit* location | 	 1
5. 'Enter blocx numoar
"~~ from Part 11. Section 2. ) '—— I
ADDITIONAL

- Section 6)
A. Total Transfers
(Ibs/yr)

6. 	 a.
5.
a
S. 	 a.
A.1 A. 2
Reporting Ranges Enter
o 1— tgg soo-999 Estimate







3. Basis of
Estimate
(enter code)
^__^^
6. bD
5. b n
C. Type of Treatment/
Disposal (enter coos

S

. c. • .i i
5. 	 c.' 'j 1 !
INFORMATION ON WASTE TREATMENT (Part III - Section 7)
A. General Wastestraam
(enter code)
7. a 1 	 1
7. a 1 1
7. a

7. a 1 (
7. a 1 I
B. Treatment
Method
(enter code)
7. h
7. b
7. b LZ
7. b




7. b I










C. Range of
Influent
Concentration
(enter code)
7. c


7. e i 1
7. c
7. c
7. "c


-



D. Sequential •
Treatment?
( check If
applicable)
7. d •
7. d
7. d
7. d
7. d
E. Treatment
Efficiency
Estimate
7. a %
7. e %
7. 9 %
7- 3 %
7. e %
F. Based on
Operating
Data?
Yes No
7. f d
7. f n
7. f n
7. f n
7. r H
EPA Form 9350-1(1-88)

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                                    TECHNICAL REPORT DATA
                             I Please read Instructions on the reverse before comnleun?j
1. REPORT NO.
 EPA-450/4-88-008
3. /RECIPIENTS ACCESSION NO.
4. TITLE ANO SUBTITLE                           ;
 Compilation  of Air Toxics Emission Inventory
   Questionnaires                          :
5. REPORT OATS
 June 1988
6. PERFORMING ORGANIZATION CODE
7. AUTHOR(S)

 Engineering-Science
8. PERFORMING ORGANIZATION REPORT .NO
9. PERFORMING ORGANIZATION NAME ANO AOORESS
 Engineering-Science
 401 Harrision  Oaks, Blvd.
 Gary, North Carolina  27513
1C. PROGRAM ELEMENT NO.
11. CONTRACT/GRANT NO.
12. SPONSORING AGENCY NAME ANO AOOR6SS
 Office of Air  Quality Planning  and Standards
 Air Quality Management Division (MD-15)
 U.S. Environmental Protection Agency
 Research Triangle  Park, NC  27711
13. TYPE OF REPORT ANO PERIOD COVERED
14. SPONSORING AGENCY CODE
15. SUPPLEMENTARY NOTES
 EPA Project Officer:   James H.  Southerland
 To  assist States  and local agencies,  EPA has developed programs  to address  the  status
 of  the air toxics problem in  their localities.   This document  provides example  ques-
 tionnaires used by several State  and  local agencies for collecting emissions  inventorv
 data for air  toxics.  The report  also contains  discussion of considerations for
 developing such questionnaires  and the elements that are likely  to be included.
7.
                                KEY WORDS ANO DOCUMENT ANALYSIS
                  DESCRIPTORS
                                               b.lOENTIFIERS/OPEN ENDED TERMS  C.  COSATI Field/Group
Air  Toxics
Urban Air Toxics
Emission Inventories
Emission Questionnaires
Air  Toxics Emission Data
8. DISTRIBUTION STATEMENT
EPA Form 2220-1 (R«». 4-77)   PREVIOUS EDITION is OBSOLETE
                                               19. SECURITY CLASS i Tins Report/
             21. NO. OP PAGES
             	194
                                               20. SECURITY CLASS I This page i
                                                                          22. PRICE

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