Section I - Facility Information

Section I - Facility Information

1. Facility Name: / Program Interest Number (5-Digit):
2.  The permittee shall submit to the Department and to the EPA, a periodic compliance certification, in accordance with N.J.A.C. 7:27-22.19(f) and the schedule for submittal of compliance certifications set forth in the compliance plan of your operating permit. The six month reports for the testing and monitoring performed from January 1 through June 30 shall be reported by July 30 of the same calendar year; and from July 1 through December 31, shall be reported by January 30 of the following calendar year.
Enter the date your initial operating permit was issued:
3. This report is due: / and covers the period from: / to:
(mo/day/year) / (mo/day/year) / (mo/day/year)
4. The methods used to determine the compliance status for each permit limitation are, at a minimum, as specified in the approved operating permit.
A six-month deviation report relating to testing and monitoring required by the operating permit, not including information for testing and monitoring which have other reporting schedules specified in the permit (i.e. CMS reported on an Excess Emission Monitoring Progress Report and stack test reports submitted to the DEP.) The six-month report must address other specified monitoring including, but not limited to, continuous and periodic monitoring data required by the permit. The six-month reports shall be submitted pursuant to N.J.A.C. 7:27-22.19(d)3 and shall address the requirements of N.J.A.C. 7:27-22.19(e).
All testing and monitoring deviations for the time period listed in Section I.3 above must be listed in Section II below, and explained in detail on forms 200A or 200B.
Section II – SIX MONTH DEVIATION REPORTS
Emission Unit/Batch Process: each unit includes ALL Operating Scenarios (OS), Steps (ST), Control Devices (CD), Emission Point (PT), Group (GR) and Equipment (E) listed under that UNIT or BP
For any deviations, enter FC or the Unit # or BP # below and into Line 1 of Section IIA or IIB on Form 200-A or 200-B / Applicable Requirement(s) Associated with a Deviation
List all Subject Items and Reference # associated with a testing or monitoring deviation.
Fill out attached a separate 200-A form for each non-compliant requirement or a 200-B form for each repetitive non-compliant requirement listed below.
For any deviation, enter the Subject Item and Ref. # on line 2 of Section IIA on Form 200A or IIB on Form 200B
FC

Use additional sheets as needed

Section III – Responsible Official Signature Statement

The signature below must be made by a responsible official, as defined at N.J.A.C. 7:27-1.4

Pursuant to N.J.A.C. 7:27-1.39(a)2: “I certify, under penalty of law, that I have personally examined and am familiar with the information submitted in this document and all attached documents and, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true , accurate and complete. I am aware that there are significant civil criminal penalties, including the possibility of fine or imprisonment or both, for submitting false, inaccurate or incomplete information.” This certification applies to the information included in this form as well as all the 200-A forms and 200-B forms and any other supplemental information included with this submittal.
Signature of Responsible Official / Date
Type or Print Name of Responsible Official / Phone
Title of Responsible Official / Fax
Address of Responsible Official / City / State / Zip Code
Section IV – 1st Direct Knowledge Official Signature Statement
The signature below must be made by the individual or individuals (may include consultants) with direct knowledge of and responsibility for the information contained within this document.
Pursuant to N.J.A.C. 7:27-1.39(a)1: “I certify, under penalty of law, that I believe the information provided in this document is true, accurate and complete. I am aware that there are significant civil and criminal penalties, including the possibility of fine or imprisonment or both, for submitting false, inaccurate or incomplete information.”
Signature of Direct Knowledge Official / Date
Type or Print Name of Direct Knowledge Official / Phone
Title of Direct Knowledge Official / Fax
Address of Direct Knowledge Official / City / State / Zip Code
Continue Section IV – 2nd Direct Knowledge Official Signature Statement
The signature below must be made by the individual or individuals (may include consultants) with direct knowledge of and responsibility for the information contained within this document.
Pursuant to N.J.A.C. 7:27-1.39(a)1: “I certify, under penalty of law, that I believe the information provided in this document is true, accurate and complete. I am aware that there are significant civil and criminal penalties, including the possibility of fine or imprisonment or both, for submitting false, inaccurate or incomplete information.”
Signature of Direct Knowledge Official / Date
Type or Print Name of Direct Knowledge Official / Phone
Title of Direct Knowledge Official / Fax
Address of Direct Knowledge Official / City / State / Zip Code

Mail (1) Copy to: United States Environmental Protection Agency, Region II

Air Compliance Branch

290 Broadway

New York, New York 10007-1866

Mail (1) Copy to the appropriate Department of Environmental Protection Regional Office:

New Jersey Department of Environmental Protection
Air Compliance & Enforcement
Central Regional Office / For facilities located in the following counties:
Burlington, Mercer, Middlesex, Monmouth and Ocean Counties
Mail Code 22-03A
PO Box 420
Trenton, NJ 08625-0420
New Jersey Department of Environmental Protection
Air Compliance and Enforcement
Northern Regional Office
7 Ridgedale Avenue
Cedar Knolls, NJ 07927 / For facilities located in the following counties:
Bergen, Essex, Hudson, Hunterdon, Morris, Passaic, Somerset, Sussex, Warren, and Union Counties
New Jersey Department of Environmental Protection Air Compliance & Enforcement, Southern Regional Office
2 Riverside Drive, Suite 201
Camden, NJ 08103 / For facilities located in the following counties:
Atlantic, Camden, Cape May, Cumberland, Gloucester, and Salem Counties

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