DAQ-2024-010160

Utah Division of Air Quality Date __________________________
New Source Review Section Company ______________________
Site/Source_____________________
Form 15c

Portable General Permit Application

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:

Phone No.: ( )
FAX No.: ( )

2. Company contact for environmental issues:

Phone 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
than 100?

† Yes † No

8. Standard Industrial Classification Code
[ ] [ ] [ ] [ ]

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
of occurrence:

12. For existing equipment in operation without prior permit, enter initial operation
date:

13. Has equipment been modified, moved or the capacity increased since November 29, 1969: † Yes † No
If yes: Specify what equipment:

1

2
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.

Signature: Title:

16.
________________________
Name (Typed or printed)

17. Telephone Number:
( )

18. Date:

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