DEEP USE ONLY LAST INSPECTION EPA CLASS

 NRC INSPECTION MANUAL NMSSDWM MANUAL CHAPTER 2401 NEAR‑SURFACE
170505 CAA(B)HEAT ED 23 MANDATORY MODIFICATIONS INSPECTIONS RECORD
Npdes Storm Water Construction Compliance Inspection Report (for

072010 SPPPFORM30 INSPECTION RECORD FOR ACTIVITIES UNDER STORMWATER GENERAL
1 THE APPLICABLE MOTOR VEHICLE CATEGORY FOR VEHICLE INSPECTION
1030282 003 57391 H UMAN CREMATORY COMPLIANCE INSPECTION CHECKLIST

Pre-Inspection Questionnaire (PIQ)



DEEP USE ONLY


Last Inspection: _________________


EPA Class: _____________________

DEEP USE ONLY LAST INSPECTION EPA CLASS

Update: _________________________


CDEEP USE ONLY LAST INSPECTION EPA CLASS DEEP USE ONLY LAST INSPECTION EPA CLASS lient: __________________________


Sequence: _______________________


Town: ___________________________


Premise: ________________________

DEEP USE ONLY LAST INSPECTION EPA CLASS

Pre-Inspection Questionnaire (PIQ)


Print or type unless otherwise noted. Please submit this completed questionnaire to 79 Elm Street, Hartford, CT 06106. If you have any

questions please contact us at (860) 424-3702 or by Fax at (860) 424-4082

Part 1: General Premises Information

1. Company Name:      

2. Premises Address:      

City/Town:       State:    Zip Code:      

3. Mailing Address (if different from premises address):      

City/Town:       State:    Zip Code:      

4. On Site Contact:       Title:      

Email Address:       Phone Number:      

5. Corporate Name:       Date Owned:      

6. Corporate Address (if different from premises address):      

City/Town:       State:    Zip Code:      

7. Corporate Contact:       Title:      

Business Phone:       ext.       Fax:      

E-mail:      

8. Nature of Operation:      

SIC Code:       NAICS Code:      

9. Calendar year of date being submitted:      


Part 2: Process Information


DEEP CODE:       Page     of    

Company Name:      


Emission Unit

Number

(EMU#)

Air Bureau Registration or New Source Review Permit Numbers. Do not use Title V or GPLPE permit numbers

Source Description

Vent ID

Dates of Installation, Last Modification, and Removal from Service

Primary/Secondary Air Pollution Control System

Typical

Daily, Weekly and

Annual Hours of Operation


Temp

(ºF or ºC)

Input Material

Material Usage

Hrs/ day

Hrs/ wk

Hrs/yr

Peak Daily Usage

(lbs, gal, or tons /day)

Typical Daily Usage

(lbs, gal, or tons /day)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Notes:      




Part 3: Chemical and Material Listing


DEEP CODE:       Page     of    

Company Name:      



Chemical/Material


Purpose


Annual Usage

/Units

Storage Tank I.D.

( A=above

B=below)


Storage Tank Capacity/Units


Number of Tanks


Submerged Fill Pipe?

(y/n)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Notes:      

Part 4: Fuel Burning Sources


DEEP CODE:       Page     of    

Company Name:      




Emission

Unit

Number

(EMU#)


Air Bureau Registration or Permit No.


Source Description


Fuel Type


Dates of Installation, Last Modification, and Removal from Service


Max. Fuel Burning Design (Include Units)


Sulfur Content (% by weight)


Max. Burner Rating (Include Units)


Annual Usage (Include Units)


Primary/Secondary Air Pollution Control System


CEM

(Y or N)/

Pollu-tant(s)


Date of Last DEEP Approved Stack Test Program/

Pollutants Tested

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


Notes:      


Part 5: Hazardous Air Pollutants Used on the Premises


5.1: Section 22a-174-29 R.C.S.A. Table 29-1 Hazardous Air Pollutants used (Connecticut list) (Check all that apply according to instructions)


Chemical CAS #

1,1,2 ‑ Trichloroethane1 79‑00‑51

1,1,2,2 ‑ Tetrachloroethane1 9‑34‑51

1,2 ‑ Dichloroethane1 (a.k.a. ethylene dichloride) 107‑06‑21

2,4,6 ‑ Trichlorophenol1 88‑06‑21

2‑Acetylamino fluorene1 53‑96‑31

3,3' ‑ Dichlorobenzidine1 91‑94‑11

4,4' ‑ Methylene bis (2‑chloraniline)1 (a.k.a. “MOCA”) 101‑14‑41

4‑Aminobiphenyl1 92‑67‑11

4‑Dimethylaminoazobenzene1 60‑11‑71

4‑Nitrobiphenyl1 92‑93‑31

Acrylonitrile1 107‑13‑11

Aflatoxins (44‑7) 83219‑44‑7

Aflatoxins (45‑8) 83219‑45‑8

Arsenic & compounds (as As) 7440‑38‑2

Arsenic pentoxide 1303‑28‑2

Arsine 7784‑42‑1

Asbestos1 1332‑21‑41

Auramine 2465‑27‑2

Azathioprine 446‑86‑6

Benzo(a)pyrene 50‑32‑8

Benzene1 71‑43‑21

Benzidine1 92‑87‑51

Beryllium 7440‑41‑7

Beryllium oxide 1304‑56‑9

Beryllium sulfate 13510‑49‑1

beta‑Napthylamine 91‑59‑8

beta‑Propiolactone1 57‑57‑81

bis‑Chloromethyl ether1 542‑88‑11

Chlorambucil 305‑03‑3

Chlordane1 57‑74‑91

Chlorinated camphene1 (a.k.a. “toxaphene”) 8001‑35‑21

Chlornaphthazine 494‑03‑1

Chlorobenzilate 510‑15‑4

Chloroform1 67‑66‑31

Chloromethyl methyl ether1 107‑30‑21

Chromic acid and chromates (as Cr)

Chromite ore processing (chromate) as Cr

Chromium, metal 7440‑47‑3


Chemical CAS #

Coal tar pitch volatiles 8007‑45‑2

Coke oven emissions

Cyclophosphamide 50‑18‑0

Dibromochloropropane1 96‑12‑81

Diethyl sulfate1 64‑67‑51

Diethylstilboestriol 39011‑86‑4

Dimethyl sulfate1 77‑78‑11

Dioxane, technical grade1 123‑91‑11

Estrogens

Ethylene dichloride1 (a.k.a. 1,2 - dichloroethane) 107‑06‑21

Heptachlor1 76‑44‑81

Hexachloroethane1 67‑72‑11

Kepone 143‑50‑0

Melphalan 148‑82‑3

MOCA1 (a.k.a. 4,4-methylene bis (2-chloraniline)) 101‑14‑41

Morpholine 110‑91‑8

Mustard gas 505‑60‑2

Myleran 55‑98‑1

n‑Nitrosodimethylamine1 62‑75‑91

Nickel (metal) 7440‑02‑0

Nickel carbonyl, as Ni 13463‑39‑3

Nickel sulfide 12035‑72‑2

Nickel sulfide roasting, dust (as Ni)

Nickel sulfide roasting, fume

Nickel, water soluble compounds (as Ni) ‑‑‑

Nitrogen mustard 55‑86‑7

o‑Toluidine1 95‑53‑41

Oxymetholone 434‑07‑1

Perchloroethylene1 (a.k.a. tetrachloroethylene) 127‑18‑41

Phenacetin 62‑44‑2

Polynuclear aromatic hydrocarbons (PAH) 50‑32‑8

Thorium dioxide 1314‑20‑1

Toxaphene1 8001‑35‑21

Treosulfan 299‑75‑2

Trichloroethylene1 79‑01‑61

Vinyl chloride1 75‑01‑41


1Compound also listed in Part 5.2, “Section 112 Hazardous Air Pollutants” (federal list)



5.2: CAA Section 112 Hazardous Air Pollutants (federal list) (Check all that apply according to instructions)


Chemical CAS #

Acetaldehyde 75‑07‑0

Acetamide 60‑35‑5

Acetonitrile 75‑05‑8

Acetophenone 98‑86‑2

Acetylaminofluorene(2)2 53‑96‑32

Acrolein 107‑02‑8

Acrylamide 79‑06‑1

Acrylic Acid 79‑10‑7

Acrylonitrile2 107‑13‑12

Allyl Chloride 107‑05‑1

Aminobiphenyl(4)2 92‑67‑12

Aniline 62‑53‑3

Anisidine(O) 90‑04‑0

Antimony Compounds

Arsenic Compounds (Inorganic Including Arsine)

Asbestos2 1332‑21‑4 2

Benzene2 71‑43‑22

Benzidine2 92‑87‑5 2

Benzotrichloride 98‑00‑7

Benzyl Chloride 100‑44‑7

Beryllium Compounds

Biphenyl 192‑52‑4

Bis(2‑Ethylhexyl)Phthalate(Dehp) 117‑81‑7

Bis(Chloromethyl)Ether2 542‑88‑12

Bromoform 75‑25‑2

Butadiene(1,3) 106‑99‑0

Cadmium Compounds

Calcium Cyanamide 156‑62‑7

Captan 133‑06‑2

Carbaryl 63‑25‑2

Carbon Disulfide 75‑15‑0

Carbon Tetrachloride 56‑23‑5

Carbonyl Sulfide 463‑58‑1

Catechol 120‑80‑9

Chloramben 133‑90‑4

Chlordane2 57‑74‑92

Chlorine 7782‑50‑5

Chloroacetic Acid 79‑11‑8

Chloroacetophenone(2) 532‑27‑4

Chlorobenzene 108‑90‑7

Chlorobenzilate 510‑15‑6

Chloroform2 67‑66‑32

Chloromethyl Methyl Ether2 107‑30‑22


Chemical CAS#

Chloroprene 126‑99‑8

Chromium Compounds

Cobalt Compounds

Coke Oven Emissions

Cresol(M) 108‑39‑4

Cresol(O) 95‑48‑7

Cresol(P) 106‑44‑5

Cresols/Cresylic Acid 1319‑77‑3

Cumene 98‑82‑8

Cyanide Compounds

D(2,4), Salts And Esters 94‑75‑7

Dde 3547‑04‑4

Diazomethane 334‑88‑3

Dibenzofurans 132‑64‑9

Dibromo‑3‑Chloropropane(1,2)2 96‑12‑82

Dibutylphthalate 84‑74‑2

Dichlorobenzene(1,4)(P) 106‑46‑7

Dichlorobenzidine(3,3)2 91‑94‑12

Dichloroethyl Ether 111‑44‑4

Dichloropropene(1,3) 542‑75‑6

Dichlorvos 62‑73‑7

Diethanolamine 111‑42‑2

Diethyl Analine (N,N) 121‑69‑7

Diethyl Sulfate2 64‑67‑52

Dimethoxybenzidine(3,3') 119‑90‑4

Dimethyl Aminoazobenzene2 60‑11‑72

Dimethyl Benzidine(3,3') 119‑93‑7

Dimethyl Carbamoyl Chloride 79‑44‑7

Dimethyl Formamide 68‑12‑2

Dimethyl Hydrazine(1,1) 57‑14‑7

Dimethyl Phthalate 131‑11‑3

Dimethyl Sulfate2 77‑78‑12

Dinitro‑O‑Cresol(4,6), And Salts 534‑52‑1

Dinitrophenol(2,4) 51‑28‑5

Dinitrotoluene(2,4) 121‑14‑2

Dioxane(1,4)2 123‑91‑12

Diphenylhydrazine(1,2) 122‑66‑7

Epichlorohydrin 106‑89‑8

Epoxybutane(1,2) 106‑88‑7

Ethyl Acrylate 140‑88‑5

Ethyl Benzene 100‑41‑4

Ethyl Carbamate 51‑79‑6

Ethyl Chloride 75‑00‑3

5.2 CAA Section 112 Hazardous Air Pollutants, (federal list) cont’d


Chemical CAS #

Ethylene Dibromide 106‑93‑4

Ethylene Dichloride2 107‑06‑22

Ethylene Glycol 107‑21‑1

Ethylene Imine 151‑56‑4

Ethylene Oxide 75‑21‑8

Ethylene Thiourea 96‑45‑7

Ethylidene Dichloride 75‑34‑3

Formaldehyde 50‑00‑0

Glycol Ethers

Heptachlor2 76‑44‑82

Hexachlorobenzene 118‑74‑1

Hexachlorobutadiene 87‑68‑3

Hexachlorocyclopentadiene 77‑47‑4

Hexachloroethane2 67‑72‑12

Hexamethylene‑1,6‑Diisocyanate 822‑06‑0

Hexamethylphosphoramide 680‑31‑9

Hexane 110‑54‑3

Hydrazine 302‑01‑2

Hydrochloric Acid 7647‑01‑0

Hydrogen Fluoride 7664‑39‑3

Hydroquinone 123‑31‑9

Isophorone 78‑59‑1

Lead Compounds

Lindane (All Isomers) 58‑89‑9

Maleic Anhydride 108‑31‑6

Manganese Compounds

Mercury Compounds

Methanol 67‑56‑1

Methoxychlor 72‑43‑5

Methyl Bromide 74‑83‑9

Methyl Chloride 74‑87‑3

Methyl Chloroform 71‑55‑6

Methyl Hydrazine 60‑34‑4

Methyl Iodide 74‑88‑4

Methyl Isobutyl Ketone 108‑10‑1

Methyl Isocyanate 624‑83‑9

Methyl Methacrylate 80‑62‑6

Methyl Tert Butyl Ether 1634‑04‑4

Methylene Bis(2‑Chloroaniline)(4,4)2 101‑14‑42

Methylene Chloride 75‑09‑2

Chemical CAS #

Methylene Diphenyl Diisocynate 101‑68‑8

Methylenedianiline(4,4') 101‑77‑9

Mineral Fibers

Naphthalene 91‑20‑3

Nickel Compounds

Nitrobenzene 98‑95‑3

Nitrobiphenyl(4)2 92‑93‑32

Nitrophenol(4) 100‑02‑7

Nitropropane(2) 79‑46‑9

Nitroso‑N‑Methylurea(N) 684‑93‑5

Nitrosodimethylamine(N)2 62‑75‑92

Nitrosomorpholine(N) 59‑89‑2

Parathion 56‑38‑2

Pentachloronitrobenzene 82‑68‑8

Pentachlorophenol 87‑86‑5

Phenol 108‑95‑2

Phenylenediamine(P)106‑50‑3

Phosgene 75‑44‑5

Phosphine 7803‑51‑2

Phosphorus 7723‑14‑0

Phthalic Anhydride 85‑44‑9

Polychlorinated Biphenyls 1336‑36‑3

Polycyclic Organic Matter

Propane Sultone(1,3) 1120‑71‑4

Propiolactone(Beta)2 57‑57‑82

Propionaldehyde 123‑38‑6

Propoxur 114‑26‑1

Propylene Dichloride 78‑87‑5

Propylene Oxide 75‑56‑9

Propylenimine(1,2) 75‑55‑8

Quinoline 91‑22‑5

Quinone 106‑51‑4

Radionuclides (Including Radon)

Selenium Compounds

Styrene 100‑42‑5

Styrene Oxide 96‑09‑3

Tetrachlorodibenzo‑P‑Dioxin(2,3,7,8) 1746‑01‑6

Tetrachloroethane(1,1,2,2)2 79‑34‑52

Tetrachloroethylene2 127‑18‑42

Titanium Tetrachloride 7550‑45‑0





5.2 CAA Section 112 Hazardous Air Pollutants, (federal list) cont’d

Chemical CAS#

Toluene 108‑88‑3

Toluene Diamine(2,4) # 95‑80‑7

Toluene Diisocyanate(2,4) 584‑84‑9

Toluidine(O)2 95‑53‑42

Toxaphene2 8001‑35‑22

Trichlorobenzene(1,2,4) 120‑82‑1

Trichloroethane(1,1,2)2 79‑00‑52

Trichloroethylene2 79‑01‑62

Trichlorophenol(2,4,5) 95‑95‑4

Trichlorophenol(2,4,6)2 88‑06‑22

Triethylamine 121‑44‑8

Trifluralin 1582‑09‑8

Trimethylpentane(2,2,4) 540‑84‑1

Vinyl Acetate 108‑05‑4

Vinyl Bromide 593‑60‑2

Vinyl Chloride2 75‑01‑42

Vinylidene Chloride 75‑35‑4

Xylene(M) 108‑38‑3

Xylene(O) 95‑47‑6

Xylene(P) 106‑42‑3

Xylenes Mixed 1330‑20‑7


2Compound also listed in Part 5.1, “Section 22a-174-29 R.C.S.A. Table 29-1 Hazardous Air Pollutants” (Connecticut list)



5.3: Check here if NONE of the chemicals in Parts 5.1 or 5.2 are used on the premises.




Part 6: Toxics Information


DEEP CODE:       Page     of    

Company Name:      



Emission Unit Number (EMU#)

Source Description

Vent I.D.

Property Line Distance (Ft.)

Chemical Name/CAS Number

Batch Time

(Hours)

% Control

Actual Emission Rate (lbs/hr)

Maximum Allowable Stack Concentration (ug/m3) (DEEP use only)

Max. Allowable Emission Rate (lbs/hr or TPY) (DEEP use only)

Air Bureau Reg. Or Permit No.

Stack Height (Feet)

Exhaust Gas Flowrate (ACFM)

DEEP Comment

(DEEP use only)

8-HR HLV (ug/m3) (DEEP Use use only)

Method of Data

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


Check here if additional sheets are necessary, and label and attach them to this sheet.


Notes:      


Part 7: Certification

The individual(s) responsible for actually preparing the questionnaire must sign this part. This questionnaire will be considered incomplete unless all required signatures are provided.


“I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on reasonable investigation, including my inquiry of the individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief.


I understand that a false statement in the submitted information may be punishable as a criminal offense, in accordance with section 22a-175 of the General Statutes, pursuant to section 53a-157b of the General Statutes, and in accordance with any other applicable statute.


I certify that this questionnaire is on complete and accurate forms as prescribed by the commissioner without alteration of the text.”





     

Authorized Signature

Date



     




     

Name of Signatory (print or type)

Title (if applicable)























DEEP-AIR-PIQ-001 2 Rev. 09/19/17


10A NCAC 14J 1750 INSPECTIONS ALL MUNICIPAL LOCKUPS SHALL
15A NCAC 18A 2511 INSPECTIONS (A) EACH PUBLIC SWIMMING
15A NCAC 18A 2834 COMPLIANCE INSPECTIONS AND REPORTS (A)


Tags: inspection, class