Air Quality Permitting and Enforcement Forms

Section A - Facility Information
Document Title	Description	Formats
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 Change	Form 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 Changes	Form A-3 should list all emission sources and control devices (equipment) being affected by the application.	PDF \| Word
A4 Facility Emission Sources	Form 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 A - Facility Information
Document Title	Description	Formats
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 Change	Form 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 Changes	Form A-3 should list all emission sources and control devices (equipment) being affected by the application.	PDF \| Word
A4 Facility Emission Sources	Form 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 C - Control Equipment
Document Title	Description	Formats
C1 Control Device and Methods	Form 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 Filters	Form C2 should be completed for all fabric filter control devices (e.g. baghouses, cartridge filters, etc.).	PDF \| Word
C3 Electrostatic Precipitator	Form C3 should be completed for all electrostatic precipitator control devices.	PDF \| Word
C4 Thermal or Catalytic Incinerators	Form C4 should be completed for all thermal or catalytic incinerator control devices.	PDF \| Word
C5 Cyclone/Multicyclone	Form C5 should be completed for all cyclone or multicyclone control devices.	PDF \| Word
C6 Adsorbers	Form C6 should be completed for all adsorber control devices (e.g. carbon adsorption systems).	PDF \| Word
C7 Scrubbers	Form C7 should be completed for all scrubber control devices (e.g. gaseous absorbers, wet scrubbers).	PDF \| Word
C8 Condensers	Form C8 should be completed for all condenser control devices.	PDF \| Word

Section D - Emission Estimations
Document Title	Description	Formats
D1-1 Materials Used Master List	Form 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 Solids	Form 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 Calculations	Form 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 Calculator	Form 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 Calculations	Form 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 Balance	Form 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 Emissions	Form 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	Description	Formats
E1 Title V Information	Form E1 contains general information on the Title V facility being permitted.	PDF \| Word
E2 Compliance Plan	Form 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 Certification	Form 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 Schedule	Form E4 is to be used to indicate compliance or non-compliance with applicable Title V requirements.	PDF \| Word

Section M - Dispersion Modeling
Document Title	Description	Formats
M1 Aerscreen Model Input Parameters	Form 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 Parameters	Form M-2 should be completed for each facility submitting a refined model. *	PDF
M2 Worksheet	N/A	Excel

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

Section R - Dry Cleaners
Document Title	Description	Formats
Drycleaner Registration Form	Fill out relevant info for your drycleaners.	PDF

Section S - Stage 1 (Gasoline Dispensing)
Document Title	Description	Formats
S1 Gasoline Dispensing Facility	Mecklenburg 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 Requirements	Mecklenburg County Air Quality (MCAQ) Form S2 contains specific equipment/process-related information on the facility being permitted.	PDF \| Word
S3 Facility Name/Ownership Change	Mecklenburg 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 Title	Description	Formats
A1-6H Facility - General Information	Mecklenburg 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 Coatings	Form B4-6H contains specific equipment and process-related information about the facility being permitted.	PDF \| Word
D1-6H Annual Material Usage and VOC Emissions Determination	Form 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 Determination	N/A	Excel

Miscellaneous Application Forms
Document Title	Description	Formats
Zoning Determination Instructions	The 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 Instructions	Application forms are available for Non-Title V and Title V facilities.	PDF \| Word
Appendix A - Completeness Checklist	The following information is being supplied to assist the applicant in determining application completeness.	PDF \| Word
Appendix B - Regulated Air Pollutants	This 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 Exemption	This 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	Description	Formats
Boiler Construction/Operation Notification	This 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 Notification	One notification per structure must be filled out. Be sure to include a copy of the asbestos inspection report.	PDF
Quarry Change Notification	N/A	PDF
Visible Emissions Test Notification	Use this form if this test is only for the determination of opacity.	PDF


Reporting Forms
Document Title	Description	Formats
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 Reporting	List 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 quarter	PDF
Semi Annual Report for Boilers NSPS Subpart Dc	This form is used to report fuel consumption for boilers using distillate oil or distillate oil in combination with natural gas.	PDF
Tank Wash Reporting	N/A	PDF
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 \| Word

Monitoring / Recordkeeping Forms
Document Title	Description	Formats
Electro Plating Daily Records	Record last bath solution addition, daily tank operation and surface tension records.	PDF
EPA Visible Emission Observations	Record observations for visible emissions.	PDF
Industrial Objectionable Odors Citizen’s Log	Record odor detection: time of detection, duration of odor, where it was detected, describe odor, and level of odor.	PDF
NSPS Subpart OOO Inspection Log	Answer 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 Title	Description	Formats
Baghouse/Filter Daily Pressure Monitoring Log	Record 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 Log	Record the inches of water, if any maintenance was required and initial. Monthly.	Excel

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

Stage I (Gasoline Dispensing) Reporting and Notification Forms
Document Title	Description	Formats
6C Combined Notifications Form for New Gasoline Dispensing Facility	Owner/operators of new GDF’s must complete and submit this form upon startup of gasoline dispensing operations.	PDF
S1 Gasoline Dispensing Facility	Mecklenburg 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 Requirements	Mecklenburg County Air Quality (MCAQ) Form S2 contains specific equipment/process-related information on the facility being permitted.	PDF
S3 Facility Name/Ownership Change	Mecklenburg 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 Checklist	Follow along the questions to complete your inspection.	PDF
Performance Test Notification	The 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 Report	Record 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