Utah Form 15C – Fill Out and Use This PDF

An Approval Order to construct must be approved before any equipment can be operated. Please refer to the Approval Order application instructions for specific details required to complete the application. Please print or type all information requested. All information requested herein must be completed and submitted before an engineering review can be completed. Please contact the New Source Review Section of the Division of Air Quality with any questions at (801) 536- 4000. Written inquiries may be addressed to: Division of Air Quality, New Source Review Section, P.O. Box 144820, Salt Lake City, Utah 84114-4820.

General Owner And Facility Information

1.	Company name and address:			2. Company contact for environmental issues:
	Phone No.:	(	)	Phone No.: (	)
	FAX No.:	(	)	FAX No.: (	)
				E-mail address:
3.	Owners name and address:
	Phone no.:	(	)
	FAX no.:	(	)

E-mail address:

	4.	Identify any current Approval Order(s):
		AO#_________________Date______________					AO#_________________Date______________
		AO#_________________Date______________					AO#_________________Date______________
		AO#_________________Date______________					AO#_________________Date______________
	5.	If request for modification, previous permit # and date:					DAQE-AN__________________	DATE: ____/____/____
	6.	Type of operation:		Aggregate Processing Plants			Asphalt Plants		Concrete Batch Plants
	7.	Total company employees greater				8. Standard Industrial Classification Code
		than 100?				[ ] [ ] [	] [ ]
		Yes	No
	9.	Application for:
		New equipment					Modification
		Existing equipment operating without permit
	10. For new equipment or modification, enter estimated start date:
	11. For change of permittee, enter date					12. For existing equipment in operation without prior permit, enter initial operation
		of occurrence:				date:
	13. Has equipment been modified, moved or the capacity increased since November 29, 1969:								Yes	No
		If yes: Specify what equipment:
							1

14.Equipment list (Table 1 and 2 Attach as Appendix A)

15.I hereby certify that the information and data submitted in and with this application is completely true, accurate and complete, based on reasonable inquiry and to the best of my knowledge and belief.

General Permit Application

Form 15c

Instructions

1.Identify the name, address, phone number, and fax number of the legal entity that operates the equipment.

2.Identify the person who is to be contacted regarding this application; also include the phone number and fax number of this person.

3.If you are not the owner of the equipment under this application, enter the name, address, phone number, and fax number of the owner.

4.List any valid Approval Orders (AO) which are for equipment at this site.

5.Indicate previous AO number (if any) and date for AO modification.

6.State the type of operation.

7.Indicate if the total number of people employed by your company is over 100 people.

8.Using the provided list of business codes (page 8), enter the code which best describes your business activity at this facility.

9.Check all applicable boxes

Existing Equipment Operating Without permit - equipment which has been in operation without a prior permit issued by the state.

Modification - existing equipment which is physically altered by the removal, addition, or non-identical replacement of parts.

10.Enter the start date new equipment or modification.

11.For cases in this category, enter the future date when the change is anticipated.

12.For this category of equipment, enter the date when this equipment was first operated.

13.This is for equipment that was operated before November 29, 1969. Indicate whether equipment has been moved, modified or increased capacity since that date. Specify what equipment this includes.

14.Attach as Table 1 and 2 to the application a list of all portable equipment (NSPS/MACT - Table 1 and Non-NSPS - Table 2) that is owned or operated by the company. Forms are available from DAQ for these two tables.

15.Signature of authorized company agent.

16.Name of signing party.

17.Telephone number of signing party.

18.Date of application.

Additional information may be required for some projects. If so, the reviewing engineer will contact the individual listed in question number 2.

f:\aq\engineer\generic\Forms 2010\Form15c Portable Generic Permit Application.doc Revised 12/20/10

2