Air Quality Permitting and Enforcement Forms

Section A - Facility Information
Document TitleDescriptionFormats
A1 Facility General Information The A1 form is required for each permit application. Mecklenburg County Air Quality (MCAQ) Form A1 contains general information on the facility being permitted. PDF | Word
A2 Notification ChangeForm A2 must be submitted along with form A1 for the following changes: Administrative Amendment, Change in Ownership, Relocation within the Facility, Like-for-Like Replacement, 502(b)(10) Notification (Title V only), and Request for Renewal (Title V only).PDF | Word
A3 Emission Source ChangesForm A-3 should list all emission sources and control devices (equipment) being affected by the application. PDF | Word
A4 Facility Emission SourcesForm A4 should list all emission sources and control devices (equipment) at the facility as well as manufacture, installation, modification, and relocation date(s).PDF | Word
A5 Insignificant Activities Form A5 should list all insignificant activities exempt from permitting per MCAPCO Regulation 1.5211-"Applicability".PDF | Word

Section B - Process Equipment
Document TitleDescriptionFormats
B Emission Source InformationThis form is to be completed for all processes or emission sources and is to be attached to all other applicable Section B forms. PDF | Word
B1 Emission SourceThis form is used for any process or emission source which is not covered under other specific emission source forms.PDF | Word
B2 Fuel Combustion SourceForm B2 should be completed for all fuel combustion emission sources (e.g., generators, boilers, burn-off ovens, bake-on ovens, bakery ovens, process heaters). PDF | Word
B2-G Internal Combustion EnginesForm B2-G should be completed for all generators.PDF | Word
B3 IncineratorsForm B3 should be completed for each incinerator on site. PDF | Word
B4 Coating/Finishing/PrintingForm B4 should be completed for each single press where inks or coatings are applied to a material. Multiple presses or printing sources of the same type would not be considered a single emission source.PDF | Word
B5 Manufacturing Chemicals/Coating/InksForm B5 should be completed for each emission source used in the manufacture of chemicals (e.g., HCl, SO2, solvent containing coatings, inks, or other solvent containing products).PDF | Word
B6 Storage Silos/BinsForm B6 should be completed for all storage silos or bins that store raw materials or final products that result in particulate or other regulated pollutant emissions.PDF | Word
B7 Liquid Storage TankForm B7 should be completed for each non-exempt storage tank that may store a liquid that results in emissions of regulated air pollutants. MCAPCO 1.5211 – “Applicability” specifies exemptions for storage tanks.PDF | Word

Section C - Control Equipment
Document TitleDescriptionFormats
C1 Control Device and MethodsForm C1 should be completed for all control devices and/or control methods that do not have a specific control device form.PDF | Word
C2 Fabric FiltersForm C2 should be completed for all fabric filter control devices (e.g. baghouses, cartridge filters, etc.).PDF | Word
C3 Electrostatic PrecipitatorForm C3 should be completed for all electrostatic precipitator control devices.PDF | Word
C4 Thermal or Catalytic IncineratorsForm C4 should be completed for all thermal or catalytic incinerator control devices.PDF | Word
C5 Cyclone/MulticycloneForm C5 should be completed for all cyclone or multicyclone control devices.PDF | Word
C6 AdsorbersForm C6 should be completed for all adsorber control devices (e.g. carbon adsorption systems).PDF | Word
C7 ScrubbersForm C7 should be completed for all scrubber control devices (e.g. gaseous absorbers, wet scrubbers).PDF | Word
C8 CondensersForm C8 should be completed for all condenser control devices.PDF | Word

Section D - Emission Estimations
Document TitleDescription Formats
D1-1 Materials Used Master ListForm D1-1 provides an updated list of all coatings, inks, solvents, etc. that are being used by the facility. This form should also be updated and resubmitted when reporting new materials to MCAQ.PDF | Word
D1-3 Pounds VOC Per Gallon SolidsForm D1-3 should be used to calculate the pounds VOC per gallon solids of a material as it is applied. This information is used to determine compliance with MCAPCO 2.0900. PDF | Word
D1-4 Total VOC Emissions CalculationsForm D1-4 should be used to calculate the total VOC emissions from materials (coatings, inks, solvents, etc.) used at VOC emission sources. *PDF | Word
D1-5 Mass Balance Hazardous Emissions CalculatorForm D1-5 is to be used to calculate the state regulated toxic air pollutants (TAPs) and the federally regulated hazardous air pollutants (HAPs) emissions from materials (coatings, inks, solvents, etc.) used at VOC emission sources. *PDF | Word
D2-1 Other Emissions CalculationsForm D2-1 should be used to demonstrate how emissions are calculated for pollutants other than VOC, TAPs and HAPs that have been calculated by mass balance.PDF | Word
D2-2 Summary of Emissions - Non-Mass BalanceForm D2-2 should be used to summarize the emission calculations that were described on Form D2-1 and calculated in the supporting spreadsheets or hand calculations.PDF | Word
D3-1 Facility-Wide Criteria Pollutant/Hap/Tap EmissionsForm D3-1 should be used to summarize the emissions from Forms D1-4, D1-5, and D2-2. This should be a facility-wide total.PDF | Word

*This form uses the mass balance method. If emission factors are used, use Form D2-1.

Section E - Special Title V Forms
Document Title DescriptionFormats
E1 Title V InformationForm E1 contains general information on the Title V facility being permitted.PDF | Word
E2 Compliance PlanForm E2 should be completed for each emission source in order to indicate the monitoring, test methods, recordkeeping, and reporting that are or will be required.PDF | Word
E3 Title V Compliance CertificationForm E3 must be completed for each Title V application. If this information is not supplied, the application will be considered incomplete.PDF | Word
E4 Compliance ScheduleForm E4 is to be used to indicate compliance or non-compliance with applicable Title V requirements.PDF | Word

Section M - Dispersion Modeling
Document TitleDescriptionFormats
M1 Aerscreen Model Input ParametersForm M-1 should be completed for each facility submitting a screening model or when requesting that MCAQ conduct a screening model for a toxics review. *PDF | Word
M2 Aermod Model Input and Output ParametersForm M-2 should be completed for each facility submitting a refined model. *PDF 
M2 WorksheetN/AExcel

*A toxics review may be required due to a permit application, MACT applicability determination, or call by the Director.

Section R - Dry Cleaners
Document TitleDescriptionFormats
Drycleaner Registration FormFill out relevant info for your drycleaners. PDF 

Section S - Stage 1 (Gasoline Dispensing)
Document TitleDescriptionFormats
S1 Gasoline Dispensing FacilityMecklenburg County Air Quality (MCAQ) Form S1 contains general information on the facility being permitted for new equipment installation or for modification of an existing, permitted process. PDF | Word
S2 Stage 1 Vapor Control RequirementsMecklenburg County Air Quality (MCAQ) Form S2 contains specific equipment/process-related information on the facility being permitted. PDF | Word
S3 Facility Name/Ownership ChangeMecklenburg County Air Quality (MCAQ) Form S3 contains general information on the existing facility with a legal name or ownership change. PDF | Word

Section 6H – Paint Stripping & Surface Coating
Document TitleDescriptionFormats
A1-6H Facility - General InformationMecklenburg County Air Quality (MCAQ) Form A1-6H contains general information on the autobody or miscellaneous surface coating facility being permitted. Word
B4-6H Emission Sources Autobody-Surface CoatingsForm B4-6H contains specific equipment and process-related information about the facility being permitted.PDF | Word
D1-6H Annual Material Usage and VOC Emissions DeterminationForm D1-6H provides a list of all paints, coatings, solvents, paint strippers, etc. that are being used by the facility by category for each year. PDF | Word
D1-6H Annual Material Usage and VOC Emissions DeterminationN/AExcel

Miscellaneous Application Forms
Document TitleDescriptionFormats
Zoning Determination InstructionsThe Mecklenburg County Air Pollution Control Ordinance (MCAPCO) requires that Air Quality Permit applications include a Zoning Determination to ensure that a proposed facility is consistent with applicable zoning requirements.PDF | Word
Air Permit Application General InstructionsApplication forms are available for Non-Title V and Title V facilities.PDF | Word
Appendix A - Completeness ChecklistThe following information is being supplied to assist the applicant in determining application completeness. PDF | Word
Appendix B - Regulated Air PollutantsThis appendix is intended to serve as a reference to identify both locally and federally regulated air pollutants that must be addressed in permit applications.PDF 
TC-MCAQ Application for Tax Certification and ExemptionThis Application Form is to be used only for air-cleaning device(s) under the authority of Mecklenburg County Air Quality.PDF 

Notification Forms
Document Title DescriptionFormats
Boiler Construction/Operation NotificationThis form is due within 30 days of the construction, reconstruction, or installation of a boiler subject to NSPS Subpart Dc –Standards of Performance for Small Industrial-Commercial-Institutional Steam Generating Units.PDF 
NESHAP Demolition/Renovation NotificationOne notification per structure must be filled out. Be sure to include a copy of the asbestos inspection report.PDF 
Quarry Change NotificationN/APDF 
Visible Emissions Test NotificationUse this form if this test is only for the determination of opacity. PDF 

Reporting Forms
Document TitleDescriptionFormats
6 Month Monitoring Report (SIXMON)Use this form to summarize all monitoring on a 6-month or more frequent basis as required by your part 71 permit.PDF
 Annual Emissions Reporting Form   The annual emissions report shall include all supporting documentation, including emission rate, product usage, operating hours, and all relevant information for emission calculation. PDF
Annual Fuel Usage Report   This form is used to report type and quantity of fuel consumed by combustion sources at your facility.PDF
 Annual Particulate Emissions  List the emissions by process or as required in the permit reporting requirements. There may be more than one process per permit.PDF
Annual VOC ReportingList the coating / solvent, amount used, amount of VOC in each and how much VOC emitted. For the year.PDF
Quarterly VOC Reporting   List the coating / solvent, amount used, amount of VOC in each and how much VOC emitted. For the quarterPDF
Semi Annual Report for Boilers NSPS Subpart DcThis form is used to report fuel consumption for boilers using distillate oil or distillate oil in combination with natural gas.PDF
Tank Wash ReportingN/APDF
Title V Annual Compliance Certification Form   Regardless of the format you choose to use for your annual compliance certification, you must meet minimum requirements shown in the following tables and/or in your Title V permit.PDF

Monitoring / Recordkeeping Forms
Document TitleDescription Formats
Electro Plating Daily RecordsRecord last bath solution addition, daily tank operation and surface tension records. PDF 
EPA Visible Emission ObservationsRecord observations for visible emissions. PDF 
Industrial Objectionable Odors Citizen’s LogRecord odor detection: time of detection, duration of odor, where it was detected, describe odor, and level of odor. PDF
NSPS Subpart OOO Inspection LogAnswer the following questions: Is water properly flowing to each discharge spray nozzle in the wet suppression system? And if not, what corrective actions were taken to repair the equipment?PDF

Baghouse-Filter Monitoring Logs
Document TitleDescriptionFormats
Baghouse/Filter Daily Pressure Monitoring LogRecord the inches of water, if any maintenance was required and initial. Daily. Excel
Baghouse/Filter with Temperature Monthly Monitoring Log
Record the inches of water, baghouse/filter inlet temperature (°F), if any maintenance was required and initial. Monthly. 
Excel
Baghouse/Filter without Temperature Monthly Monitoring LogRecord the inches of water, if any maintenance was required and initial. Monthly.Excel

Scrubber Monitoring Logs
Document TitleDescriptionFormats
Scrubber Daily Monitoring Log without pHRecord inches of water liquid flow rate, if any maintenance was required and initial. Daily. Excel
Scrubber Monthly Monitoring Log with pHRecord inches of water liquid flow rate, pH, if any maintenance was required and initial. Daily. Excel
Scrubber Monthly Monitoring Log without pHRecord inches of water liquid flow rate, if any maintenance was required and initial. Monthly. Excel
Scrubber Weekly Monitoring Log with pHRecord inches of water liquid flow rate, pH if any maintenance was required and initial. Monthly.Excel
Scrubber Weekly Monitoring Log without pHRecord inches of water liquid flow rate, if any maintenance was required and initial. Weekly.Excel

Stage I (Gasoline Dispensing) Reporting and Notification Forms
Document TitleDescriptionFormats
6C Combined Notifications Form for New Gasoline Dispensing FacilityOwner/operators of new GDF’s must complete and submit this form upon startup of gasoline dispensing operations.PDF
S1 Gasoline Dispensing FacilityMecklenburg County Air Quality (MCAQ) Form S1 contains general information on the facility being permitted for new equipment installation or for modification of an existing, permitted process.PDF | Word
S2 Stage 1 Vapor Control RequirementsMecklenburg County Air Quality (MCAQ) Form S2 contains specific equipment/process-related information on the facility being permitted.PDF
S3 Facility Name/Ownership ChangeMecklenburg County Air Quality (MCAQ) Form S3 contains general information on the existing facility with a legal
name or ownership change
PDF | Word
Gasoline Vapor Recovery System 1-2-3 Inspection ChecklistFollow along the questions to complete your inspection. PDF 
Performance Test NotificationThe Performance Test Notification Form (“PTNF”) provides MCAQ with sufficient information to determine potential problem areas related to a proposed source testing project before the actual test date.PDF
Stage I Gasoline Dispensing Facility Annual ReportRecord the following information for calendar year: enter the month and gallons for the highest monthly gasoline throughout and the total gallons of gasoline dispensed.PDF