-------
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.
FOIU1.TX
£!/
HAME
STREET
ZIP
OFFICE USE OHUY_
cummin
SIC
». SU»STA«C£S
**** KXVXXKMMXXXXXKXXXXMNMKXXX
US»3 ACETALDEHYOE
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J704 ACXYLOHITRUE
PLEASE CIXCLE TH£ APPROPRIATE/ UHUS
AMOUHT PRODUCED AMOUNT
BIXECTLY BY-fROOUCT U3E3
XXXXXXXX XXXXXXXX ' X4XXIXXX
ALtYL CHLORIDE
1210.5 ARSENIC CI1IORGAHIC)
12301 ASBESTOS
>5ZJl BEMZEHE
)1002 JEHZYL CHLORIDE
SERYLLIUfl
J.3XGAL
18XOAL
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LBXGAL
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V
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LBXGAL
IHCO«POR.Ar£D IH PRODUCT.
TRADE
MAflE
TRADE KAME PRODUCT
xuxxxxxxxxxxxxxxxxxxxx
SUPPLIER
XXXXKXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IRADE KAME PRODUCT
. 1IXXXXXXXXXXMMXXXXXXXXM
SUPPLIER
NAME
ADDRESS
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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
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9 NAME OF AUTHORIZED AGENT 10 TELEPHONE
1. NAME OF OWNER /FIRM
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20. FACILITY LOCATION (NUMBER AND STREET ADDRtSs]
II NUMQER INO STREET ADDRESS
£., NUMUtH AND STREET ADDRESS
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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
-------
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
-------
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
-------
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
-------
-------
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
-------
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
-------
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.
-------
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)
-------
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
-------
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
-------
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
-------
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
!
j
1
!
*
1
i
t
i
i
t
i
I
1
i
i
;
'
1
i
|
AH347-3
August 1985
DEQ FORM HO. 16337
-------
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
-------
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 ;
!
|
i
I
1
t
!
1
!
i
* 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
-------
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
-------
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)
L f
1
AH347-5
August 1985
DEQ FORM NO. 1683!
-------
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
-------
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
.
i
i
|
1
AH347.8
August 1985
DEQ FORM NO. 16838
-------
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
-------
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
-------
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
-------
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
-------
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
-------
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 onsite 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
-------
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
-------
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...)
(tablecoo 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
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We We This This chemical
package manufacture chemical nay be present,
this this aay be an in our
chemical chemical intermediate incinerator
E 3
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E 3
C 3
C 3
C 3
C 3
C 3
E 3
E 3
[ 3
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E 3
£ 3
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E 3
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[ 3
C 3
£']
C 3
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[ 3
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C 3
C 3
C 3
C 3
C 3
C 3
C 3
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C 3
r 3
C 3
C. 3
[ 3
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C 3
C 3
C 3
C 3
E 3
C 3
C 3
C 3
[ 3
[ 3
C 3
C- 3
C 3
[ 3
[' 3
C 3
C 3
L 3
C 3
C 3
C ]
C 3
C 3
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C ]
C 3
C 3
C 3
C.3
C 3
C 3
C 3
C 3
C 3
C 3 .
L ]
C 3
[ 3
[ 3
C 3
C 3
C ]
C 3
C 3
C 3
[ 3
[ 3
C 3
C 3
C ]
C 3
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[ 3
[ 3
i 3
C 3
C 3
C 3
i ]
C 3
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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-------
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-M74 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
-------
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
LJ 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 IVSupplemental Information.)
EPA Form 9350-1(1-38)
-------
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)
-------
(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)
-------
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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