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For Air Quality Use Only
 
ANNUAL EMISSION INVENTORY REPORTING FORM
Source ID (Permit) Number: 123456       Reporting Year: 2011
Company Name: ABC Company
Source (Facility) Name ABC Company
Source (Facility) Address: 1212 Las Vegas Blvd.
City, State, and Zip Las Vegas, NV 89000
Mailing Address:  
(If different than facility address.)  
  Regulated Pollutant Emissions (tons/year)
  PM10 PM2.5 NOx CO SOx VOC HAP
  TOTAL Allowable Emissions* for the Entire Source: 1.33 0.85 9.78 8.64 0.23 0.65 0.21
  Total Actual Emissions for the Entire Source: 0.38 0.19 1.13 2.03 0.04 0.14 0.06
I certify that, based on information and belief formed after reasonable inquiry, the information contained in this document is true, accurate, and complete.
  09/07/12
Signature of Responsible Official Signature Date
  Responsible Official Name and Title: John Doe, Director of Facilities
  Phone Number: 702-555-1212 Responsible Official E-Mail Address: johndoe@cox.net
* Use Allowable Emissions if Potential to Emit (PTE) is not listed in the permit or Technical Support document (TSD). Page 1    of 3
ANNUAL EMISSION INVENTORY REPORTING FORM
For Operating Hour-Based Actual Emissions Reporting
Source ID (Permit) Number: 123456 Reporting Year: 2011
EU EU Description: Permitted  Actual Ratio   Regulated Pollutant Emissions in Tons Per year (TPY)
Hours          (P) Hours          (P) A/P   PM10 PM2.5 NOx CO SOx VOC HAP
A01 Patterson Kelly Hydronic       Heating Boiler HWH01 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,550 0.29 Actuals 0.02 0.02 0.09 0.20 0.00 0.01 0.01
A02 Patterson Kelly Hydronic       Heating Boiler HWH02 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,188 0.25 Actuals 0.01 0.01 0.07 0.17 0.00 0.01 0.00
A03 Patterson Kelly Hydronic       Heating Boiler HWH03 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,550 0.29 Actuals 0.02 0.02 0.09 0.20 0.00 0.01 0.01
A04 Patterson Kelly Hydronic       Heating Boiler HWH04 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,350 0.27 Actuals 0.02 0.02 0.08 0.19 0.00 0.01 0.01
A05 Patterson Kelly Hydronic       Heating Boiler HWH05 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,188 0.25 Actuals 0.01 0.01 0.07 0.17 0.00 0.01 0.00
A06 Patterson Kelly Hydronic       Heating Boiler HWH06 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,650 0.30 Actuals 0.02 0.02 0.09 0.21 0.00 0.01 0.01
A07 Patterson Kelly Domestic       Hot Water Boiler HWH10 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,188 0.25 Actuals 0.01 0.01 0.07 0.17 0.00 0.01 0.00
A08 Patterson Kelly Domestic       Hot Water Boiler HWH11 8,760     PTE* 0.06 0.06 0.30 0.69 0.01 0.04 0.02
  2,250 0.26 Actuals 0.02 0.02 0.08 0.18 0.00 0.01 0.01
A09 Patterson Kelly Domestic       Hot Water Boiler HWH07 8,760     PTE* 0.04 0.04 0.19 0.43 0.01 0.03 0.01
  2,550 0.29 Actuals 0.01 0.01 0.06 0.13 0.00 0.01 0.00
A10 Patterson Kelly Domestic       Hot Water Boiler HWH08 8,760     PTE* 0.04 0.04 0.19 0.43 0.01 0.03 0.01
  2,388 0.27 Actuals 0.01 0.01 0.05 0.12 0.00 0.01 0.00
A11 Patterson Kelly Domestic       Hot Water Boiler HWH09 8,760     PTE* 0.04 0.04 0.19 0.43 0.01 0.03 0.01
  2,188 0.25 Actuals 0.01 0.01 0.05 0.11 0.00 0.01 0.00
A12 Steam Boiler 8,760     PTE* 0.05 0.05 0.09 0.29 0.01 0.04 0.01
  3,700 0.42 Actuals 0.02 0.02 0.04 0.12 0.00 0.02 0.00
PTE Subtotals for the Sheet (tons/year): 0.65 0.65 3.06 7.10 0.12 0.45 0.20
Actual Emissions Subtotals for the Sheet: 0.18 0.18 0.84 1.96 0.03 0.13 0.06
* Use Allowable Emissions if Potential to Emit (PTE) is not listed in the permit or Technical Support document (TSD). Page 2    of 3
ANNUAL EMISSION INVENTORY REPORTING FORM
For Operating Hour-Based Actual Emissions Reporting
Source ID (Permit) Number: 123456 Reporting Year: 2011
EU EU Description: Permitted  Actual Ratio   Regulated Pollutant Emissions in Tons Per year (TPY)
Hours          (P) Hours          (P) A/P   PM10 PM2.5 NOx CO SOx VOC HAP
B01 Emergency Generator 500     PTE* 0.20 0.20 6.72 1.54 0.11 0.20 0.01
  21 0.04 Actuals 0.01 0.01 0.28 0.07 0.00 0.01 0.00
C01 Cooling Tower 1 8,760     PTE* 0.24            
  3,400 0.39 Actuals 0.09 0.00 0.00 0.00 0.00 0.00 0.00
C02 Cooling Tower 2 8,760     PTE* 0.24            
  3,300 0.38 Actuals 0.09 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
    1     PTE*              
  0 0.00 Actuals 0.00 0.00 0.00 0.00 0.00 0.00 0.00
PTE Subtotals for the Sheet (tons/year): 0.68 0.20 6.72 1.54 0.11 0.20 0.01
Actual Emissions Subtotals for the Sheet: 0.19 0.01 0.28 0.07 0.00 0.01 0.00
* Use Allowable Emissions if Potential to Emit (PTE) is not listed in the permit or Technical Support document (TSD). Page 3    of 3