MISSISSIPPI DEPARTMENT OF ENVIRONMENTAL QUALITY
TITLE V PROGRAM ANNUAL EMISSIONS REPORTING FORM
P.O. BOX 2261
JACKSON, MS  39225-2261

In accordance with 11 Miss. Admin. Code Pt. 2, R. 6.6., all sources that choose to base their annual Title V fee on actual emissions shall submit, by July 1 of each year, an inventory of emissions for the previous calendar year.

MDEQ Facility ID #:  ____________
AI ID:  _____

Facility:	_____________________
Site Address:	_____________________
	_____________________    
	_______________County

If actual emissions are reported, they should be the actual emissions that were emitted from the facility during calendar year 2017.  The annual permit fee is due on September 1st of each year.

Pollutant	Annual Allowable (Potential) Emission Rate (TPY)	FOR INFO ONLY Actual Emission Rate (TPY) Reported for Calendar Year (2016) 	Actual Annual (2017) Emission Rate (TPY)	
Particulate Matter				
Sulfur Dioxide				
Nitrogen oxides				
Carbon Monoxide				
VOC				
Total reduced sulfur compounds				
Lead				
CFC/HCFC, Total				
Other				
HAP, Total (VOC)				
HAP, Total (NON VOC)				
VOC reflects total VOC from the facility including VOCs that are HAPs.
Attach calculations, monitoring data, measurements, etc. from which actual emission rates were determined. Actual emission rates will not be accepted unless the method of calculation is attached.
I, the undersigned, am the owner or authorized representative of the facility described on this fee form.  I certify that the statements and calculations made on this form are complete and accurate to the best of my knowledge.

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Signature		Date

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Typed or Printed Name	Title