DAQ-2024-010177

Utah Division of Air Quality Revised: 6/21/06
SMALL SOURCE EXEMPTION REGISTRATION

Businesses eligible for this exemption shall not: 1) emit more than 5 tons per year of each of the
following pollutants: sulfur dioxide (SO2), carbon monoxide (CO), nitrogen oxides (NOx), particulate
matter (PM10), ozone (O3), or volatile organic compounds (VOCs) or 2) emit more than 500 pounds
per year of any single hazardous air pollutant (HAP), and emit more than 2000 pounds per year
for any combination of HAPs, or 3) emit less than 500 pounds per year of any air contaminant not
listed in (1)( or (2) above and less than 2000 pounds per year of any combination of air contaminants
not listed in (1) or (2) above.

Please keep copies of the registration notice and worksheets on site at your business to verify your
permit exemption status. Please be aware that the small source exemption only exempts your
business from the permitting requirements of R307-401-5 through 8 of the Utah Administrative Code,
not other applicable air quality regulations.

1. Business Name and Mailing Address:
____________________________
____________________________
____________________________
____________________________
Phone # ( ____ ) ____-__________
Fax # ( ____ ) ____-__________
2. Business Contact for Air Quality Issues:
______________________________
______________________________
______________________________
______________________________
Phone # ( ____ ) ____-___________
Fax # ( ____ ) ____-___________
3. Owners Name and Mailing Address:
_______________________________
_______________________________
_______________________________
_______________________________
Phone # ( ____ ) ____-__________
Fax # ( ____ ) ____-__________
4. Business Location (street address if
different from above and directions to site):
_________________________________
_________________________________
_________________________________
_________________________________
5. County where business is located:
______________________________
6. Start-up Date of Business:
Month: _____________ Year: _______

7. Briefly describe your process by describing end products, raw materials, and process
equipment used at your business. Attach additional sheets if necessary.

8. List any pollution control equipment:

9. Typical operating Schedule:
10. Annual Emission Rates:
Provide an estimate of the actual annual emissions of the following air contaminants from your
business. Emission calculation worksheets are available for some common processes.
Please attach all worksheets and calculations.
Sulfur Dioxide (SO2)….. ______ lbs / year Particulate Matter (PM10) ….……... ______ lbs / year
Carbon Monoxide (CO) ______ lbs / year Ozone (O3) ……………………..…. ______ lbs / year
Nitrogen Oxides (Nox) ______ lbs / year Volatile Organic Compounds (VOC)______ lbs / year
Other Air Contaminants ______ lbs / year Describe__________________________________
HAZARDOUS AIR POLLUTANTS:
Complete Attachment C before selecting one of the following emission estimate ranges.
For an individual hazardous air pollutant:
0 - 250 lbs/year: ________ 250-350 lbs/year: __________ 350-500 lbs/year: _________
For a combination of hazardous air pollutants:
0-1000 lbs/year: ________ 1000-1500 lbs/year: __________ 1500-2000 lbs/year: _________

11. □ By checking this box, I hereby certify that the information and data submitted in this notice
fully describes this site and only this site and is true, accurate, and complete, based on
reasonable inquiry and to the best of my knowledge. I recognize that falsification of the
information and data submitted in this notice is a violation of R19-2-115, Utah
Administrative Code.

□ By checking this box, I understand that I am responsible for determining whether I remain
eligible for this exemption before making operational or process changes in the future and
agree to notify the Division of Air Quality when this business is no longer eligible for this
exemption.

Signature of Owner/Manager: __________________________________Title: __________________

Print Name: ____________________________ Phone # : (_____)___________ Date: ___________

Division Reviewer: _____________________________________________Date: ____________________
Small Source Applicable Yes___ No___ ____________________________________________________