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F *j \ °n ñn 0 !o †j t çs c! : çs ¸ úm úm ’ çs Œn $ × × ! × × × × × Æn Æn ! × × × !o × × × × ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ çs × × × × × × × × × J S : PART 1 - IDENTIFYING INFORMATIONCompany NameFacility NamePrincipal Facility Product or BusinessPrimary SIC/NAICS Physical AddressMailing AddressInitial Title V Permit NumberIssuance DatePermit Modification and/or Renewal Number(s)Permit Modification and/or Renewal Issuance Date(s) Certification PeriodEnvironmental Contact PersonPhone #E-mailResponsible OfficialPhone #E-mail PART 2 - CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESSI certify, based on information and belief formed after reasonable inquiry, the statements and information in this document are true, accurate, and complete.Responsible Official SignatureDateResponsible Official Title PART 3 - ANNUAL COMPLIANCE CERTIFICATION DATA [A] Condition Identification [B] Compliance Determination Method(s), Information, and/or Facts [C] Compliance Status Throughout Period [D] Current Compliance Status[1] Permit and Condition Number[2] Applicable Requirement Continuous (C) or Intermittent (I)In Compliance (C) or In Deviation (D) PART 4 - STANDARD CONDITIONS COMPLIANCE CERTIFICATION[1] Standard Conditions Dated: [2] FORMCHECKBOX By checking this box, the source certifies that they were in continuous compliance with all Standard Conditions contained in the Title V permit(s) for the duration of the certification period. Method(s) used to determine compliance were those listed in each condition. FORMCHECKBOX By checking this box, the source certifies that they were in continuous compliance with all Standard Conditions contained in the Title V permit(s) for the duration of the certification period EXCEPT for the conditions listed in the table below. [A] Condition Identification [B] Compliance Determination Method(s), Information, and/or Facts [C] Compliance Status Throughout Period [D] Current Compliance Status [1] Permit and Condition Number[2] Applicable Requirement Continuous (C) or Intermittent (I)In Compliance (C) or In Deviation (D) PART 5 - DEVIATION REPORTING Question Yes (Y) or No (N)Are there any deviations that occurred during the certification period that were reported to or identified by DEQ during the certification period? If yes, you may incorporate any deviation reports by reference and/or complete Table 1.Are there any deviations that occurred during the certification period that have not yet been reported to or identified by DEQ that are being noted in this report? If yes, complete Table 2. Table 1: Deviations that occurred during the certification period that were previously reported to or identified by DEQ Term or Condition IDEmission Unit IDPollutantMonitoring Method & FrequencyDate(s) of DeviationDurationCause of DeviationCorrective Actions Taken Table 2: Deviations that occurred during the certification period that have not yet been reported to or identified by DEQTerm or Condition IDEmission Unit IDPollutantMonitoring Method & FrequencyDate(s) of DeviationDurationCause of DeviationCorrective Actions Taken Annual Compliance Certification Form Part 70 Permit DEQ Form 100-924 Page PAGE 1 Adopted 1/3/2011 Annual Compliance Certification DEQ Form 100-924 Page PAGE 2 Adopted 1/3/2011 ! " # / 1 2 ? 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