LE-06 Part 70 Low-Emitting Facility General Permit Qualifications Compliance Certification Air Quality Permit Program Doc Type: Permit Application Refer to the Handbook and Application Instructions for the Part 70 Low-Emitting Facility General Permit for form instructions. a) AQ Facility ID No.: b) Agency Interest ID No.: c) Facility Name:

All Air Permit applicants are required to give a description of the compliance status of the stationary source. Please note, indicating non-compliance in this form will not necessarily result in enforcement action.

1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) Standards of Compliance Compliance Performance for Non-Compliance* Non-Compliance Volatile Organic Not Applicable Not Applicable Liquid Storage Vessels (Including *If you checked Non- Petroleum Liquid Compliance, you must Storage Vessels) for agree to the compliance Which Construction, schedule in Form LE-00 Reconstruction, or in order to be eligible for Modification this permit. Commenced after July 23, 1984 (40 CFR pt. 60, subp. Kb; Minn. R. 7011.1520) Standards of Compliance Compliance Performance for Non-Compliance* Non-Compliance Compression Ignition Not Applicable Not Applicable Internal Combustion Engines (40 CFR pt. *If you checked Non- 60, subp. IIII; Minn. Compliance, you must R. 7011.2305) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 1 of 7 1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) Standards of Compliance Compliance Performance for Non-Compliance* Non-Compliance Spark Ignition Not Applicable Not Applicable Internal Combustion Engines (40 CFR pt. *If you checked Non- 60, subp. JJJJ and Compliance, you must Minn. R. 7011.2310) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. T; Minn. R. Compliance, you must 7011.7200) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. MMMM; Minn. Compliance, you must R. 7011.8090) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. NNNN; Minn. Compliance, you must R. 7011.7900) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 2 of 7 1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. PPPP; Minn. Compliance, you must R. 7011.8130) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. QQQQ; Minn. Compliance, you must R. 7011.8000) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. RRRR; Minn. Compliance, you must R. 7011.7900) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 60, *If you checked Non- subp. EE; Minn. R. Compliance, you must 7011.2550) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 3 of 7 1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. WWWW; Compliance, you must Minn. R. 7011.7800) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. ZZZZ; Minn. Compliance, you must R. 7011.8150) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. DDDDD; Minn. Compliance, you must R. 7011.7050) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. JJJJJJ) Compliance, you must agree to the compliance schedule in Form LE-00 in order to be eligible for this permit.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 4 of 7 1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. HHHHHH) Compliance, you must agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. National Emission Compliance Compliance Standards for Non-Compliance* Non-Compliance Hazardous Air Not Applicable Not Applicable Pollutants (40 CFR pt. 63, *If you checked Non- subp. JJ; Minn. R. Compliance, you must 7011.7340) agree to the compliance schedule in Form LE-00 in order to be eligible for this permit. Air Quality Emission Compliance Compliance Fees Non-Compliance Non-Compliance (Minn. R. 7002.0025) Check Compliance here Check Compliance here unless you have an unless you have an overdue overdue emission fee bill emission fee bill that you (including late fees.) have not paid and do not intend to pay by the time you get a permit. Minnesota and Compliance Compliance National Ambient Air Non-Compliance Non-Compliance Quality Standards Unknown Unknown (Minn. R. 7009.0010 - 7009.0080) You may only check You may only check Unknown if your facility Unknown if your facility has has never modeled never modeled ambient air ambient air impacts or impacts or done ambient air done ambient air testing. testing.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 5 of 7 1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) Air Emission Permits Compliance Compliance (Minn. R. 7007.0050 - 7007.1850) You may check You may check Compliance Compliance if you are in here if, by applying for and compliance with all state obtaining a permit, you have and federal permitting satisfied all state and federal requirements (including permitting requirements that the requirement to obtain apply to your facility. a state permit and/or permit amendment(s) Non-Compliance under Minnesota's prior air permitting rules), and you have submitted a complete permit application by the deadline listed in Minn. R. 7007.0350. Non-Compliance Check Non-Compliance if any of the above conditions are not true. Preventing Compliance Compliance Particulate Matter Non-Compliance Non-Compliance from Becoming Airborne Check Non-Compliance Check Non-Compliance (Minn. R. 7011.0150) if you have received an here if you are not order or a permit complying with either the condition from the MPCA permit or the order, and do to control fugitive dust not intend to comply by the and you are not time you get your permit. complying with either permit or the order. Performance Tests Compliance Compliance (Minn. R. 7017.2000) Non-Compliance Non-Compliance Not Applicable Not Applicable Check Not Applicable if Check Not Applicable if you you have never will not conduct an air conducted an air emission performance test emission performance before you get your permit. test.

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 6 of 7 1a) 1b) 1c) 1d) 1e) Requirement That Compliance Status On Briefly Describe the Non-Compliance How Did You Determine if You Were In or Out Compliance Status On the is Basis of the Date of Application (If You Checked Non-Compliance in of Compliance? Day You Receive Your Certification (Check One) the Previous Column) (Monitoring, Reporting, Recordkeeping and/or Permit Operation and Maintenance Methods) (Check One) Emission Inventory Compliance Compliance (Minn. R. 7019.3000 Non-Compliance Non-Compliance - 7019.3010) Check Non-Compliance if the MPCA has sent an emission inventory form to you to fill out and you didn't fill it out and return it. Noise Pollution Compliance Compliance Control Non-Compliance Non-Compliance (Minn. R. 7030.0010 - 7030.0080) Check Compliance if Check Compliance if noise noise pollution has never pollution has never been been tested for your tested for your facility. facility. Standards of Compliance Compliance Performance for Non-Compliance Non-Compliance Stationary Internal Unknown Unknown Combustion Engines Not Applicable Not Applicable (Minn. R. 7011.2300) You may only check You may only check Unknown if you have Unknown if you have never never done opacity or done opacity or emissions emissions testing at your testing at your facility. facility. Standards of Compliance Compliance Performance for Non-Compliance Non-Compliance Industrial Process Unknown Unknown Equipment Not Applicable Not Applicable (Minn. R. 7011.0700 - 7011.0735) You may only check You may only check Unknown if you have Unknown if you have never never done opacity or done opacity or emissions emissions testing at your testing at your facility. facility. Any condition Compliance Compliance included in your Non-Compliance Non-Compliance most recent Air Not Applicable Not Applicable Emission Permit List below:

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats aq-f4-le06 • 1/9/15 Page 7 of 7