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1.
FUEL BURNING EQUIPMENT INFORMATION

Unit
ID:

Equipment ID:

Permit Number:

File Name:

Check
all that apply: 

New Unit

Is this a Replacement Unit?  If yes, specify Unit
to be replaced:

Is this a Fuel Addition/Change to an Existing Unit? 
If yes, specify addition or change:

Is this a Physical Modification to an Existing Unit? 
If yes, describe:

Other:

Type
of Unit (e.g., Fire-tube boiler, hot water heater):

Purpose
(please describe all uses, including use as a control device):

Date of Manufacture:

Installation Date:

Reconstruction/Modification
Date (if applicable):

Make:

Model:

Not available at this time

Rated
Input Capacity: x 10<sup>6 BTU/hr

Does the unit combust
a waste as defined in Section 61-62.1? Yes   No   

If yes, which waste streams?

Number
of burners:

Specify size of each burner
(in 10<sup>6 BTU/hr)

Is
this unit equipped with Low NOx burner(s)?  Yes   No

If yes, indicate for which
fuels:

Is
this unit capable of soot blowing?                  Yes   No

If yes, indicate for which
fuels:

Burner
Type

(Solid fuels only):

Pulverized      

Traveling Grate   

Underfeed Stoker

Other (specify):

Is
this unit equipped with a control device? Yes No  (If yes, complete the information on page
3 of this form.)

2.
FUEL DATA (Include All Fuels)

Fuel
Type and Grade

BTU
Content

%
Sulfur by weight

%
Ash by weight

Consumption
@ Rated Capacity (units)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

3.
EMISSION RATES BY FUEL TYPE (At Maximum Input Capacity)

Primary Fuel Type:

Pollutant

Calculated
Emissions

Calculation
Method

Uncontrolled

Controlled

(lb/hr)

(tons/yr)

(lb/hr)

(tons/yr)

Particulate
Matter (PM)

 
 
 
 
 

Particulate
Matter < 10 Micron (PM<sub>10)

 
 
 
 
 

Particulate
Matter < 2.5 Micron (PM<sub>2.5)

 
 
 
 
 

Sulfur
Dioxide (SO<sub>2)

 
 
 
 
 

Carbon
Monoxide (CO)

 
 
 
 
 

Nitrogen
Oxides (NOx)

 
 
 
 
 

Volatile
Organic Compounds (VOC)

 
 
 
 
 

Hazardous
Air Pollutant Single Greatest

 
 
 
 
 

Hazardous
Air Pollutants Total

 
 
 
 
 

 

Unit
ID:

Equipment ID