Mecklenburg County Air Quality

40 CFR 63, Subpart CCCCCC New Gasoline Dispensing Facility (GDF) Commencement of Operation /Initial and Notification of Compliance Status Form

Owner/operators of new GDF’s must complete and submit this form upon startup of gasoline dispensing operations.

Commencement of Operation Information GDF Name: GDF Address: Commencement Date of GDF Operations: Permit Number:

GDF Owner/Operator Information Owner Name: Operator Name: Address: Address: City: City: State: State:

GDF Initial/Compliance Status Notification Please indicate the compliance status for each listed regulation as being Yes, No or Not Applicable (NA) Requirements for GDF’s dispensing Compliant? Requirements for GDF’s dispensing Compliant? 10,000 - 99,999 gallons of gasoline / mo (Yes, No) ≥ 100,000 gallons of gasoline / mo (Yes, No) 63.11116(a)(1)-(4) Management Practices 63.11116(a)(1)-(4) Management Practices 63.11117(b) Fill Tube Depth 63.11117(b) Fill Tube Depth 63.11124(a) Notifications 63.11118 (b)(1) Vapor Balance System Facilities willing to comply through 63.1111(k) should attach 63.11120(a) or (b) Performance Test a written demonstration. 63.11124(b) Notifications

I acknowledge that this Initial Notification/Notification of Compliance Status is being submitted in response to 40 CFR 63, Subpart CCCCCC -National Emission Standards for Hazardous Air Pollutants for Source Category: Gasoline Dispensing Facilities as applicable, and my facility complies with the requirements as indicated and certify that the information contained herein is both truthful and accurate.

______Signature of Responsible Official** Date

______Printed Name of Responsible Official Title

** Per 40 CFR 63.2, notification forms shall be signed by: (1) For a corporation: A president, secretary, treasurer or vice president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions for the corporation, or a duly authorized representative of such person if the representative is responsible for the overall operation of one or more manufacturing, production, or operating facility. (2) For a partnership or sole proprietorship: a general partner or the proprietor, respectively. (3) For a municipality, State, Federal, or other public agency: either a principal executive officer or ranking elected official. For the purposes of this part, a principal executive officer of a Federal agency includes the chief executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e. g. a Regional Administrator of the EPA). (4) For affected sources (as defined in this part) applying for or subject to a title V permit: “responsible official” shall have the same meaning as defined in part 70 or Federal title V regulations in this chapter (42 U. S. C. 7661), whichever is applicable.

Completed forms should be mailed to the following: US EPA Region 4 AND Mecklenburg County Air Quality Director, Air, Pesticides and Toxics Management Division 2145 Suttle Avenue Atlanta Federal Center Charlotte, NC 28208-5237 61 Forsyth Street Telephone No. (704) 336-5430 Atlanta, GA 30303-3104 Amended 01/2016