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 1st of each year, an inventory of emissions, including supporting information, for the previous calendar year.  For the purpose of this year’s fee assessment, the inventory shall consist of the actual emissions emitted from the facility during Calendar Year (CY) 2020.  The submittal shall include all necessary supporting information (i.e. calculations, monitoring and testing data, measurements, etc.) from which the actual emission rates were determined.  If supporting information is incomplete or not included, actual emission rates will not be accepted and the fee will be based on allowable emissions.

	Air Reference #:	                                      
	AI ID #:	                                      

Facility:	                                                    
Site Address:	                                                    
	                                                    
	                                        County

Pollutant	
Annual Allowable
(Potential) Emission
Rate (TPY)
	
FOR INFO ONLY

Actual Emission Rate
Reported for CY 2019
(TPY)
	
Actual Emission Rate
in CY 2020 
(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)				
Particulate Matter represents any airborne finely divided solid or liquid material with an aerodynamic diameter smaller than 100 micrometers.
VOC reflects total VOC from the facility, including VOCs that are HAPs.

I, the undersigned, am the owner or authorized representative of the facility described on this form.  I certify that the statements made on this form and in the supporting information included with my submittal are complete and accurate to the best of my knowledge.

__________________________________________________	________________________
Signature		Date

__________________________________________________	________________________
Typed or Printed Name	Title