EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 United States Environmental Protection Agency Air Quality Permit by Rule for New or Modified True Minor Sources of Air Pollution in Indian Country https://www.epa.gov/tribal-air/tribal-minor-new-source-review Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country Last Modified: January 4, 2017 Version 1.0 This Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor SourceGasoline Dispensing Facilities in Indian Country applies to the construction of new, true minor source gasoline dispensing facilities or the modification of existing, true minor source gasoline dispensing facilities in Indian country. It applies only to facilities that dispense greater than 4,000,000 gallons of gasoline in National Ambient Air Quality Standard (NAAQS) ozone attainment, unclassifiable or attainment/unclassifiable areas, or dispense greater than 2,100,000 gallons of gasoline annually in NAAQS ozone nonattainment areas. A gasoline dispensing facility is any stationary facility which dispenses gasoline into the fuel tank of a motor vehicle, nonroad vehicle or equipment, includinga nonroad vehicle or nonroad engine used solely for competition. This Permit by Rule is not available for use by gasoline dispensing facilities within the geographic boundaries of the State of California. You qualify to submit a Notification of Coverage under the Permit by Rule if you meet all ofthe following criteria: • You plan to construct a true minor source gasoline dispensing facility that dispenses gasoline for resaleor non-resale purposes or you plan to modify an existing, true minor source gasoline dispensing facility that dispenses gasoline for resale or non-resale purposes; • Your new or modified true minor source gasoline dispensing facility is located within Indian country; • Your facility has a potential to emit (PTE) less than the New Source Review (NSR) major source thresholds; • If located in a serious, severe or extreme ozone nonattainment area, after the proposed construction or modification project, your facility is projected to dispense less than 8,000,000 gallons of fuel per year based on a 12-month rolling total; • If located in an attainment, unclassifiable or attainment/unclassifiable ozone area or a marginal/moderate nonattainment ozone area, after the proposed construction or modification project, your facility is projected to dispense less than 25,000,000 gallons of fuel per year based on a 12-month rollingtotal; • If located in an ozone nonattainment area, after the proposed construction or modification project,your facility is projected to dispense more than 2,100,000 gallons of fuel over a consecutive 12-month period; • If located in an attainment, unclassifiable or attainment/unclassifiable area for ozone, after the proposed construction or modification project, your facility is projected to dispense more than 4,000,000 gallons of fuel over a consecutive 12-month period; • You demonstrate, and obtain confirmation from the U.S. Environmental Protection Agency (EPA), that you have followed the screening process the EPA has provided with respect to the protection of species that are federally-listed as threatened or endangered under the Endangered Species Act (ESA) or of habitat that is federally-designated as "critical habitat" under the ESA; and # o \ I® I % ^ Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 1 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 • You demonstrate, and obtain written confirmation from the EPA, that you followed the screening process to address any effects to historic properties eligible for protection under the National Historic Preservation Act (NHPA). The reviewing authority retains discretion to terminate your coverage under the Permit by Rule and require a source- specific permit even if the above criteria are met. Reasons the reviewing authority may terminate a permitted source's coverage under the Permit by Rule include: 1. The permittee is not in compliance with the provisions of the Permit by Rule; 2. The reviewing authority determines that the emissions resulting from the construction or modification of the permitted source significantly contribute to NAAQS violations, which are not adequately addressed by the requirements in the Permit by Rule; 3. The reviewing authority has reason to believe that the permittee obtained coverage under the Permit by Rule by fraud or misrepresentation; or 4. The permittee failed to disclose a material fact required by the Notification of Coverage or the regulations applicable to the permitted source of which the applicant had or should have had knowledge at the timethe permittee submitted the Notification of Coverage. More Information Information on the definition of a "modification" and "PTE" can be found at 40 CFR 49.152(d) and in the "Instructions" document. Additional information on the applicability of the Federal Indian Country Minor NSRRule can be found at 40 CFR 49.153. Information on the ozone attainment status of the area where your facility is located can be found at: https://www.epa.gov/green-book. You may also contact your reviewing authority for information on the area's attainment status. Sources eligible for the Air Quality Permit by Rule for New or Modified True Gasoline Dispensing Facilities may also be subject to federal standards under 40 CFR 63 Subpart CCCCCC, National Emission Standards for Gasoline Dispensing Facilities, 40 CFR 60 Subpart Nil - Standards of Performance for Stationary Compression Ignition Internal Combustion Engines, 40 CFR 60 Subpart JJJJ - Standards of Performance for Stationary Spark Ignition Internal Combustion Engines, and 40 CFR 63 Subpart ZZZZ- National Emission Standards for Hazardous Air Pollutants for Stationary Reciprocating Internal Combustion Engines. The conditions applicable to sources seeking coverage under this Permit by Rule are intended to be generally consistent with the requirements in 40 CFR 63 Subpart CCCCCC, 40 CFR 60 Subpart Nil, 40CFR 60 Subpart JJJJ, and 40 CFR 63 Subpart ZZZZ. However, compliance with the applicable requirements in 40 CFR part63, Subpart CCCCCC is required independent of the conditions in the Permit by Rule, and not all requirements applicable under Subpart CCCCCC are necessarily included in the Permit by Rule. The Background Document for the Permit by Rule identifies the specific requirements in Subparts CCCCCC, Mil, JJJJ, and ZZZZ that are intended to be included in the Permit by Rule. The EPA's brochure for Subpart CCCCCC is available here: http://www.epa.gov/ttn/atw/area/gdfb.pdf. Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 2 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 Instructions Step 1: Notify your reviewing authority, including providing appropriate documentation, that you (1) meet one of the criteria listed in the EPA's screening process for the protection of any and all species that are federally-listed as threatened or endangered under the ESA or of habitat that is federally-designated as "critical habitat" under the ESA; and (2) satisfy the EPA's screening process for the NHPA. You must obtain written confirmation from the EPA that the threatened or endangered species and historic property screening procedures have been satisfied prior to submitting your Notification of Coverage under the Permit by Rule. Step 2: After receiving notification that you have successfully met the requirements of Step 1, complete all sections of the Notification of Coverage under the Permit by Rule (i.e., pages 4 - 10). If you have questions, please contactthe reviewing authority. Step 3: Certify that your existing or proposed facility is/will be in compliance with the applicable requirements as stated in 40 CFR 49.164 and submit a copy of this notification to the reviewing authority and to the tribe in the area wherethe source is located/locating. Submittal of this Notification of Coverage form also satisfies the requirement that minor sources in Indian country register with the EPA. After you submit the Notification of Coverage under the Permit by Rule to the reviewing authority: • You may commence construction of your new source or modification of your existing source under the Permitby Rule. • Your reviewing authority may request additional information from you in order to verify you are eligible for the Permit by Rule. The public reporting and recordkeeping burden for this collection of information is estimated to average 28 hours per response. Applicants are welcome to send comments on the EPA's need for the information in this application, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques, to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address. Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 3 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 United States Environmental Protection Agency Air Quality Permit by Rule for New or Modified True Minor Sources of Air Pollution in Indian Country https://www.epa.gov/tribal-air/tribal-minor-new-source-review Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country Last Modified: January 4, 2017 Version 1.0 Prior to construction or modification, complete this application and submit it to your reviewing authority. A list of reviewing authorities, their areas of coverage, and contact information can be found in Attachment D to the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country orvisit: https://www.epa.gov/tribal-air/5-source-categories-gasoline-dispensing-facilities-final-rule. For questions regarding this notification please contact your reviewing authority. For instructions on completing this application please see the document "Instructions for Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country." Section 1: Contact Information 1. Business Name: 2. Date: 3. Site Address: 4. County: 5. Name of Operator at Site (if different from owner): 6. Phone of Operator or Contact at Site (if differentfrom owner): 7. Owner: 8. Telephone Number of Owner: 9. Owner's Mailing Address: 10. Send all correspondence regarding this application to: Company Name: c/o: Address: Mi ro z 3 Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 4 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 11. Authorized contact regarding this permit application: Name: Email: Title: FAX: Phone: Section 2: Facility and Technical Information for the Notification of Coverage under theAir Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country 12. This notification is for: I | New retail gasoline dispensing facility (please describe the proposed new source). I | New non-retail gasoline dispensing facility (please describe the proposed new source). I | Modification of an existing gasoline dispensing facility. Please describe the modification below. The definition of "modification" can be found at 40 CFR 49.152(d), and in the "Instructions" document available for completing this notification form. 13. North American Industry Classification System/Standard Industrial Classification Code and/or description for the facility: 14. Will your new or modified facility be located in an ozone nonattainment area? Information on the ozone attainment status of the area where your facility is located can be found at: https://www.epa.gov/green- book. ~ Yes ~ No If you answered 'Yes/ specify the classification of the ozone nonattainment area: I | Marginal Q Moderate Q Serious Q Severe Q Extreme Notification of Coverage: Gasoline Dispensing Facilities Page 5 of 10 Version 1.0 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 15. Will the PTE of your new facility, or the increase in potential emissions from your modified existing facility, be equal to or above the applicable minor NSR thresholds listed below for ANY of the listed pollutants, both in tons per year (tpy)? Emissions from your facility may be calculated using the PTE calculator available online at: https://www.epa.gov/tribal-air/5-source-categories-gasoline-dispensing-facilities-final-rule. Be sure to include all new or modified emission units at your facility. Pollutant Attainment Area Nnmittainmunt Area CO 10 tpy 5 tpy Particulate Matter (PM) 10 tpy 5 tpy Particulate Matter (PM10) 5 tpy l tpy Particulate Matter (PM2.5) 3 tpy 0.6 tpy Sulfur Dioxide (S02) 10 tpy 5 tpy Nitrogen Oxides (NOx) 10 tpy 5 tpy Volatile Organic Compounds (VOC) 5 tpy 2 tpy I | Yes Q No If you answered 'No', your source is exempt from the minor NSR program. Please contact your reviewing authority to confirm that your facility will not need a permit. If you answered 'Yes', continue on to the nextquestion. 16. If located in an attainment, attainment/unclassifiable or unclassifiable area, will the PTE of your facility be less than 250 tpy for PM, PMio, PM2.5, VOC, NOx, CO, and S02? Be sure to include all existing, new, and modified emission units at your facility. ~ Yes ~ No If you answered 'No,' your source does not qualify for the Permit by Rule. Please contact your reviewing authority to apply for a site-specific permit. If you answered 'Yes,' continue on to the nextquestion. Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 6 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 17. If located in a nonattainment area, will the PTE of your facility for the particular nonattainment pollutant be less than the NSR major source thresholds below for ALL pollutants? Be sure to include all existing, new, and modified emission units at your facility. Pollutant Nonn tfo in men tCUissi Mention NSR Major Source Threshold Ozone Marginal 100 tpy of VOC or NOx Moderate 100 tpy of VOC or NOx Serious 50 tpy of VOC or NOx Severe 25 tpy of VOC or NOx Extreme 10 tpy of VOC or NOx PMio Moderate 100 tpy Serious 70 tpy CO Moderate 100 tpy Serious 50 tpy S02, N02, PM2.5 No nonattainment classification 100tpy Q Yes Q No | | N/A - Not located in any nonattainment area If you answered 'No/ your source does not qualify for the Permit by Rule. Please contact your reviewing authority to apply for a site-specific permit. If you answered 'Yes' or 'N/A/ continue on to the next question. 18. Do you agree to comply with all requirements of the Permit by Rule as stated in CFR 49.164? ~ Yes ~ No If you answered 'No/ your source does not qualify for the Permit by Rule under 40 CFR 49.164 and you must obtain a site-specific permit from your reviewing authority. 19. Emission Units Information regarding the existing and planned emission units at your facility is required by 40 CFR49.154 and 49.160. Please provide the information in the following table for each emission unit at the site that is or will be owned, leased or operated by the applicant. Examples of potential emission units include gasoline storage tanks, gasoline pumps and emergency engines. For each emissions unit, include supporting documentation for the PTE of each unit with your Notification of Coverage. In addition, for existing emission units, include the most recent actual annual emissions. See 40 CFR 49.154(a)(2). (For more information on how to calculate actual emissions, goto: https://www.epa.gov/tribal-air/registration-existing-true-minor-sources-air-pollution-indian-country.) As needed, please include any other relevant information with your Notification of Coverage. Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 7 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 List of Existing and Planned Emission Units (attach additional copies of this table as necessary): Unit ID# Description of Equipment imd/or Process (include any input imitermls or fuels) Miiximum Gipncity or Production Rcite Description of Pollution Control Equipment Operating Schedule Existing, New or Modified (include insLilkition (kite for existing) Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 8 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 Section 3: Information on Completing Screening Processes that Have Been Satisfied Prior to Submitting a Notification of Coverage under the Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country 20. Threatened or Endangered Species Have you obtained confirmation from the EPA that you have satisfactorily completed the screening process for the protection of species that are federally-listed as threatened or endangered under the ESA or of habitat that is federally-designated as "critical habitat" under the ESA? If you answer 'No/ you cannot gain coverage under this Permit by Rule. I | Yes Q No 21. Historic Properties Have you obtained confirmation from the EPA that you have satisfactorily completed the screening process to determine if the construction, modification or operation of your new or modified true minor source of air pollutants has the potential to cause effects to historic properties (pursuant to the NHPA)? If you answer 'No/ you cannot gain coverage under this Permit by Rule. ~ Yes Q No Section 4: Additional Information about this Air Quality Permit by Rule for New or Modified True Minor Source Gasoline Dispensing Facilities in Indian Country This section provides information on the sizes of sources in terms of emissions that are eligible for the Permit by Rule. The emission limitations and standards in this Permit by Rule are generally expected to ensure that source-wide emissions are below the rates shown in the following table: Pol 111 Unit or Concern Serious, Severe or Extreme Ozone Nomithiinment Arens Ozone Attainment, Unckissifwble or AtUnnment/UnckissiMiible Arciisiincl Modemte or IVkirgimil Ozo n e N o n ii t til i n m e n t A ren s voc 7.5 tpy 25 tpy Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 9 of 10 ------- EPA Form No. 5900-343 OMB Control No. 2060-0003 Approval expires 01/31/2023 Applicant's Statement (to he signed hy the applicant) I certify that this document and all attachments were prepared under my direction or supervision according to a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Basedon my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. Name: Name: Date: (Signature) (Print or Type) Title: Notification of Coverage: Gasoline Dispensing Facilities Version 1.0 Page 10 of 10 ------- |