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Name of Person Legally Authorized to Supply Data (Please print) <br />A <br />Title of Person Legally Authorized to Supply Data <br />GUIDANCE FOR NON-CRITERIA REPORTABLE AIR POLLUTANT EMISSION NOTICE ADDENDUM <br />Non-Criteria Reportable Air Pollutant Emission Notice Addendum: This form should be completed to report emissions of Hazardous Air Pollutants (HAP) and other <br />non-criteria reportable pollutants listed in Regulation 3, Part A, Appendix B. <br />Permit Number: For New Permit Applications leave this blank. For modifications to existing permits, please list the permit number previously issued by the APCD. <br />AIRS ID Number: For New Permit Applications leave this blank. For modifications to existing permits, please list the emissions point AIRS ID number previously issued <br />by the APCD. <br />Chemical Abstract Service (CAS) Number and Chemical Name: Please list the CAS number and common chemical name for each non-criteria reportable air pollutant <br />that is emitted from this emission point. A list of CAS numbers and common chemical names may be found in Regulation 3, Appendix B. <br />Reporting BIN: Please list the reporting BIN for each non-criteria reportable pollutant reported. The reporting BIN may be determined by reviewing Regulation 3, <br />Appendix B. <br />Reporting Scenario: The reporting scenario is established by evaluating the release point of the emission unit and the proximity of the property boundary closest to the <br />release point according to the definitions and scenarios described below. Further details on how to determine the appropriate reporting scenario are contained in <br />Regulation 3, Appendix A. The Division will assume scenario "1" if this information is left blank. Otherwise, an operator may choose scenario "1" by default or evaluate <br />the reporting scenario based on the following definitions: <br />Release Point: the lowest height above ground level from which the pollutants are emitted to the atmosphere. <br />Property Boundary: the distance from the base of the release point to the nearest property boundary. <br />Point: an individual emission point or a group of individual emission points reported on one Air Pollutant Emission Notice as provided for in Part A, section II.B.4. <br />Scenario 1: Release point less than 10 meters (- 33 feet) or property boundary less than 100 meters (- 328 feet); <br />Scenario 2: Release point equal to or greater than 10 meters (- 33 feet), but less than 50 meters (- 164 feet), or property boundary equal to or greater than <br />100 meters (- 328 feet), but less than 500 meters (- 1,640 feet); or <br />Scenario 3: Release point equal to or greater than 50 meters (- 164 feet), or property boundary equal to or greater than 500 meters (- 1,640 feet). <br />Control Equipment / Reduction (%): Please list the type of control equipment used (i.e. SCR, NSCR, Flare, Thermal Oxidizer, etc.) and report the minimum percent <br />reduction achieved by the control equipment. <br />Emission Factor: Please list the emission factor used to calculate the emission rates listed in the actual emission columns. Fill this information out if the applicant has <br />calculated emissions in lieu of having the Air Pollution Control Division (APCD) calculate the emissions for the company. <br />Emission Factor Source: Example emission factor sources include: AP-42, GRI HAP Calc., EPA TANKS, GRI GLY Calc., Manufacturer's Emission Factor, and Mass <br />Balance. <br />Uncontrolled Actual Emissions: Enter the actual uncontrolled data year (projected first year emissions for new sources) emissions (lbs/year) from the reported <br />emission point excluding any emission reduction achieved by control equipment. <br />Controlled Actual Emissions: Enter the actual controlled data year (projected first year emissions for new sources) emissions (lbs/year) from the reported emission <br />point including the emission reduction listed in the "Control Equipment Reduction (%)" column. Enter "N/A" if the emissions are uncontrolled. <br />SUBMITTAL OF THIS ADDENDUM MUST BE ACCOMPANIED BY AN AIR POLLUTANT EMISSION NOTICE (APEN) <br />Copies of this form may be obtained on the Internet at the following URL: http://www.cdphe.state.co.uslap/downloadforms.html <br />http://www cdphe state co us/ap/stationai .htnil Addendum revised December 4, 2006