<p> State of Wisconsin Air Permit Exemptions Request Form Department of Natural Resources P.O. Box 7921, Notice of Intent to Operate under s. NR 407.03(1m), Wis. Adm. Code Madison WI 53707-7921 Claim of Exemption under s. NR 406.04(1q), Wis. Adm. Code dnr.wi.gov Draft Form 4530-174 (R 01/11) </p><p>Notice: By submitting this form you are notifying the department of your intent to (1) construct or modify an emission unit under construction permit exemption listed in s. NR 406.04(1q), Wis. Adm. Code, or (2) operate a facility under the operation permit exemption listed in s. NR 407.03(1m), Wis. Adm. Code. </p><p>It is not the department's intention to use any personally identifiable information from this form for any other purpose. Wisconsin's Open Records law requires the department to provide this information to others upon request [ss. 19.31 - 19.69, Wis. Stats.]. Read instructions before completing this form. </p><p>1. Facility name mailing address Street or Route City, State, Zip Code </p><p>2. Facility location Street Address City, County </p><p>3. Responsible official Name Title Telephone </p><p>4. Permit contact person Name Title Telephone E-mail </p><p>5. Facility identification number (FID): 6. SIGNATURE OF FACILITY REPRESENTATIVE Check appropriate box □ I HEREBY SUBMIT TO THE DEPARTMENT A CLAIM OF EXEMPTION FROM CONSTRUCTION PERMIT REQUIREMENTS UNDER S. NR 406.04(1q), WIS.ADM. CODE. I have attached a check in the amount of $1250 for the exemption claim, and a complete application for a revision to my air pollution control operation permit or an amendment to my application for an operation permit. □ I HEREBY NOTIFY THE DEPARTMENT OF THE INTENT TO OPERATE THIS FACILITY UNDER THE ACTUAL EMISSIONS EXEMPTION UNDER S. NR 407.03(1m), WIS.ADM. CODE. By submitting this notification I understand that I am also requesting the following: Revocation of all air pollution control construction and operation permits and orders issued to this facility. Withdrawal of coverage of my facility from under a general or registration permit. Withdrawal of any pending air pollution control permit applications submitted by the facility.</p><p>Printed or Typed Name Title </p><p>Signature Date Signed </p><p>1 Form 4530-174 AIR POLLUTION CONTROL CONSTRUCTION AND OPERATION PERMIT AND ORDER REVOCATION APPLICATION FORM INSTRUCTIONS.</p><p>Item 1 Provide full business name and address of corporation, company, association, society, firm, partnership, individual or political subdivision of the state submitting the application. Item 2 Street address where the air pollution sources are located. Item 3 The responsible official is a person legally responsible for the operation of the permitted air pollution sources. For a corporation, this person must be the president, vice-president, secretary or treasurer, or other person with a similar level of responsibility in the company. Subsection NR 400.02(80e), Wis. Adm. Code defines "responsible official." Item 4 List the name of the Individual to contact for additional information concerning the permits and/or orders during the revocation process. Item 5 Provide the facility identification (FID) number that appears on the annual emissions inventory reports. If you do not know your FID or one has not been assigned to your facility, leave this section blank. Item 6 Check the appropriate box. Claim of exemption from construct permitting, under s. NR 406.04(1q): you must also include a check for $1250 and an application to revise your facility-wide operation permit to include the new equipment or modification. If your facility has not yet received an operation permit, then please submit an amendment to your operation permit application to include the new equipment or modification. Note: If you have not submitted a timely and complete application for a facility-wide operation permit under ch. NR 407, you are not eligible for this exemption. Also, your exemption application will not be considered complete until we receive the exemption claim fee of $1250 and the operation permit revision application or amendment to it. Notice of intent to operate under 407.03(1m): please note that this notice is also considered a request of revocation of existing permits and withdrawal of any pending permit applications, or, if appropriate, a request of withdrawal from coverage under a general or registration permits. Signature: The facility representative should review the form, sign and date. Send the original plus one copy of the submittal to the department at the address below. Keep a copy for your records.</p><p>SEND THE ORIGINAL AND ONE COPY OF THIS COMPLETED FORM TO: WISCONSIN DEPARTMENT OF NATURAL RESOURCES BUREAU OF AIR MANAGEMENT AM/7 – ACTUAL EMISSION EXEMPTION P.O. BOX 7921 MADISON, WI 53707-7921 </p><p>2</p>