APPLICATION TRANSMITTAL FORM
New Mexico Environment Department
~ Air Quality Bureau ~
(Two copies of this form must accompany operating permit application transmittal to US EPA)

PART A - Administrative Information
General Information:
Transmittal Date: 
Air Quality Bureau Permit Specialist: 
Facility Name: 
Facility Location - City: 
Facility Location - County: 
Facility Location - State: New Mexico 
State Operating Permit Number: 
Facility Primary SIC Code: 
Air Permit Contact Person: 
Air Permit Contact - Telephone: 
Air Permit Contact E-mail address: 
Company Name: 
Company Address: 		
Distance from Facility to Nearest Class I Area:
Is the Facility Within 50 Miles (80.467 km) of a Class I Area?:
Is the Facility Within 50 Miles of Indian Land?:

Transmittal Description (Place X before the appropriate information, delete this instruction)
	New Permit	
	Renewal	
	Modification	
	Acid Rain Source (TIV) 	

PART B - Technical Information (NSR limit or ≥ 100 tpy or 25 tpy of HAPs, delete this instruction) 

TV Regulated Pollutants    			      Source Description 
	CO Source (COS)			PSD (PSD)	
	TSP/PM-10 Source (PM10)			Nonattainment Area (NNSR)	
	VOC Source (VOC)			Acid Rain Source (TIV) 	
	112(b) Pollutants (112B) 			Chlorofluorocarbons (CFC) 	
	NOX Source (NOX)			Compliance Schedule (CSS)	
	SO2 Source (SO2)			Federal Facility (FED)	
	Lead Source (Lead)			Combustion Source (CMBS)	
	Green House Gases (GHG)				

Regulatory Specifications (Enter appropriate information, delete this instruction)
Units Subject to Enhanced Monitoring (40 CFR 64) (Number):	
Applicable NSPS (60):	
Applicable NESHAP (61):	
Applicable MACT (63):	

Version: 10/02/2012