Form Ncdaq R01 PDF Details

Form Ncdaq R01 is a registration statement required to be filed by foreign private issuers with the SEC in order to register their securities under the Securities Exchange Act of 1934. The form provides detailed information about the company and its securities, including the name of the issuer, principal executive office, type of organization and business description, authorized shares and par value, dividends and other distributions, officers and directors, securityholders owning more than 10% of any class of equity securities, and financial statements. This form is important for investors who want to know more about a company before investing in its securities. It can also help foreign companies access U.S. markets by providing transparency into their operations.

Form NameForm Ncdaq R01
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesSB3_Registratio n_Form ncdaq r01 form

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North Carolina Division of Air Quality (NCDAQ) Air Quality Registration Form NCDAQ R01

Instructions: Complete (Instructions on back), sign and return the original signed copy and one copy. Mail to: North

Carolina DENR, Division of Air Quality, Permits Section, 1641 Mail Service Center, Raleigh, N.C. 27699-1641

Section 1. General Information

Facility Legal Name:

Site Address :





Zip Code:


Section 2.

Responsible Official






Mailing Address:



Zip Code

Phone Number:


E-mail Address:

X Signature (Blue Ink):




Section 3: Facility Information

Facility Description:

Engine Manufacturer/Model

(e.g. CAT Model G3306)

Rated Capacity (e.g. 75 kW)


(e.g. swine gas)




Section 4: Facility Qualification





Is your emission source exempt from requiring an air quality permit? (See 15A NCAC 2Q .0102)








Is your facility required to meet Best Available Control Technology (hereinafter “SB3 State








BACT”) pursuant to the requirements of North Carolina General Statute §62-133.7(g)?


















Section 5: Verification of Best Available Control Emission Limits









For each emission(s) unit subject to SB3 verify that the engine will be designed and operated









such that it will meet the following limits at all times.









Limit oxide of nitrogen (NOx) emission to equal to or less than 0.5 g/hp-hr









Limit PM-10 emissions to equal to or less than 0.15 g/hp-hr









Limit CO emissions to equal or less than 2.75 g/hp-hr






Because an air quality permit is not required does not relieve the owner or operator from the obligation to comply with any applicable air quality emission standard. A violation of any air quality standard may subject the owner/operator of the source of emissions to enforcement pursuant to G.S. 143-215.114A, 143-215.114B, and 143-215.114C, including assessment of civil and/or criminal penalties.

Pursuant to North Carolina General Statute 143-215.3(a)(2), no person shall refuse entry or access to any authorized representative of the NC DAQ who requests entry or access for purposes of inspection, and who presents appropriate credentials, nor shall any person obstruct, hamper, or interfere with any such representative while in the process of carrying out his official duties. Refusal of entry or access may constitute grounds assessment of civil penalties.

Form NCDAQ R01

Instructions For Completing NCDAQ SB3 BACT Registration Form (Form NCDAQ R01)

Section 1

General Information

Facility Legal Name

This is the name of the facility as registered with the NC Secretary of


State (SOS). If the corporation if not registered with the NC SOS, the


Facility Legal Name should be the individual responsible for operation of


the emission source

Site Address

The physical location where the agency would go to inspect the




City or Town



ZIP Code

Postal Zone Improvement Plant (ZIP) Code

Section 2

Responsible Official

Responsible Official

The person at the facility submitting the registration form, preferably an


officer or company official.

Responsible Official

The address at which the Responsible Official receives mail.

Mailing Address



By signing this document the responsible official is stating that based on


information and belief formed after reasonable inquiry, the responsible


official affirms that the statements and information as transmitted in this


registration form are true. Note that making any false material statement,


representation or certification subjects the responsible party signing this


statement to civil and/or criminal penalties as provided in NCGS 143-


215, et.seq.

Section 3

Facility Information

Facility Description

(e.g. Landfill gas engine set)


For each engine subject to SB3 provide the manufacturer and the model


number of the engine.

Rated Capacity

Provide the nameplate output rating of the engine (either in KW or HP).


List all fuels the engine will burn.

Section 4

Facility Qualification

Qualification A

Verify that your emission units are exempted from permitting pursuant to


2Q .0102.

Qualification B

Verify that your emission unit(s) is a new renewable energy biomass


combustion process at a new renewable energy facility that delivers


electric power to an electric power supplier and therefore subject to the


SB3 Best Available Control Requirement. See North Carolina General


Statute §62-133.7(g).

Section 5

Verification of SB3 BACT Limits

Emission Limits

Verify that your emissions unit(s) will be designed and operated in a


manner sufficient to meet the listed emission limits at all times except


startup, shutdown, and malfunctions. For startup, shutdown, and


malfunctions see 15A NCAC 2D .0535.

Form NCDAQ R01