MISSISSIPPI DEPARTMENT OF ENVIRONMENTAL QUALITY
TITLE V PROGRAM ANNUAL EMISSIONS REPORTING FORM
c/o Laura James, Air Division
P.O. BOX 2261
JACKSON, MS  39225-2261

In accordance with 11 Miss. Admin. Code Pt. 2, R. 6.6., all sources shall submit, by July 1st of each year, a completed reporting form with an inventory of emissions along with supporting information for the previous calendar year.  For the purpose of this year’s emissions portion of the fee assessment, the inventory shall consist of the actual emissions emitted from the facility during Calendar Year (CY) 2022. 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 a completed form is not submitted timely or supporting information is incomplete or not included, actual emission rates will not be accepted, and the emissions portion of the fee will be based on allowable emissions. The fee also includes a complexity factor based on the number of applicable federal regulations. Facilities should confirm the applicability of the regulations listed and add any missing applicable regulations.  The “Guidance for Completing and Submitting the Annual Emissions Reporting Form (AERF) for the Purpose of Assessing the Title V Program Fee” document is available on the DEQ website.

	Air Reference #:	____________
	AI ID #:	____________

Facility:	__________________
Site Address:	__________________
	__________________
	____________County 

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

Actual Emission Rate
Reported for CY 2021
(TPY)
	
Actual Emission Rate
in CY 2022 
(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 (i.e. both filterable and condensable).
VOC reflects total VOC from the facility, including VOCs that are HAPs.

Complexity Component	
Standards Type	Standards	Confirm applicability (if no, please explain on separate page)	
 Part 60 (NSPS)	NSPS Subpart	
Y / N	

NSPS Subpart	
Y / N	

 Part 61 (NESHAPS)	  NESHAP Subpart	Y / N	
	 NESHAP Subpart	Y / N	
 Part 63 (MACT)	MACT Subpart 	
Y / N	

MACT Subpart 	
Y / N	

 Part 68 (RMP)	RMP Program 	
Y / N	

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 of Responsible Official or DAR	Title

CONTACT INFORMATION
Please review and update the information below as needed. 
Clearly indicate any updates.  Place an end date for any person who no longer has the listed relationship and add any new contacts at the bottom of the list.

Person	Title	Mailing Address	Communications	Relationship	End Date	
%%:DS_GET_AI_PERSON_MAIL_RELATE@@I%%	%%:NEXT%%	%%:NEXT%%	%%:NEXT%%	%%:NEXT%%