General Permit to Limit Potential to Emit

DEP USE ONLY

TOWN: PREM:

CLIENT:

AFS ID:

REPORT ID:

General Permit to Limit Potential to Emit

Annual Emissions Summary Form

Part I: General Information

This form shall only be completed by those permittees for which the actual emissions of any regulated air pollutant from the premises as reported in the registration for approval under this general permit or as logged pursuant to Section 5(c)(1)(C) of this general permit are at or above 80 percent of the emission limitation specified in Section 5(a) of this general permit.
1.  Premises Name:
Mailing Address:
City/Town: State: Zip Code: -
Business Phone: -- Ext. Fax: --
Contact Person: Title:
E-Mail:
2.  Premises Address:
City/Town: State: Zip Code: -
3.  Registration Number: --GPLPE Issue Date: //
4.  Reporting Period (mm/dd/yyyy): From: // To: //

Part II: Certification

“I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that, based on reasonable investigation, including my inquiry of those individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief. I understand that a false statement made in the submitted information may be punishable as a criminal offense, under Sections 22a-175 of the Connecticut General Statutes, under 53a-157b of the General Statutes, and in accordance with any other applicable statute.
I certify that the signature of the registrant or the permittee, or a duly authorized representative, being submitted herewith complies with Section 22a-174-2a(a) of the Regulations of Connecticut State Agencies.”
//
Date
Authorized Signature
Name of Signatory (print or type) / Title (if applicable)

Bureau of Air Management

DEP-AIR-SUM-003 1 of 2 Rev. 10/22/10

Part III: Premises Actual Emissions Summary

1.  Indicate pollutants for which the premises actual emissions were at or above 80% of the emission limitation as reported in the registration for approval under this general permit or as logged pursuant to Section 5(c)(1)(C) of this general permit:
PM-2.5 , PM-10 , SOx , NOx , VOC , CO , HAP (aggregate) , HAP (individual) , GHG(CO2e basis) (Complete no. 2 and 3 below for each pollutant indicated)
2.  Consecutive 12-month Aggregate Periods / 3.  Actual Criteria Pollutant Emissions, HAP Emissions and Greenhouse Gas Emissions (tons/consecutive 12-month aggregate)
From (YY) / To (YY)
February 1, 20 / January 31, 20
March 1, 20 / February 28, 20
April 1, 20 / March 31, 20
May 1, 20 / April 30, 20
June 1, 20 / May 31, 20
July 1, 20 / June 30, 20
August 1, 20 / July 31, 20
September 1, 20 / August 31, 20
October 1, 20 / September 30, 20
November 1, 20 / October 31, 20
December 1, 20 / November 30, 20
January 1, 20 / December 31, 20

Note: Submit this completed form to: Compliance Analysis & Coordination Unit

Bureau of Air Management

DEPARTMENT OF ENVIRONMENTAL PROTECTION

79 Elm Street

Hartford, Connecticut 06106-5127

Bureau of Air Management

DEP-AIR-SUM-003 2 of 2 Rev. 10/22/10