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Project Name

Project Number Sheet 1


REV DATE BY APVD REV DATE BY APVD
Owner's Name
Plant Location Units English Metric
Case Description
Pollutant Process Source (Stream No. if avail.) Measurement (estimate) method Continuous / Intermittent
Nitrogen Oxides
Total
Sulfur Oxides
Total
Particulate matter
Total
Volatile organic compounds
Total
HAPs (list by name)
Stream Name Process Source (Stream No. if avail.) Water flow kg/day Contaminant
Stream Name Process Source (Stream No. if avail.) Measurement (estimate) method Component
Stream Name Process Source (Stream No. if avail.) Measurement (estimate) method Component
Pollutant Process Source (Stream No. if avail.) Measurement (estimate) method Continuous / Intermittent
Nitrogen Oxides
Total
Sulfur Oxides
Total
Particulate matter
Total
Volatile organic compounds
Total
Stream Name Process Source (Stream No. if avail.) Water flow kg/day Contaminant
Boiler blowdown TDS
Corrosion inhibitor
Cooling water blowdown TDS
Fouling inhibitor
Chloride
Stream Name Process Source (Stream No. if avail.) Measurement (estimate) method Component
Solid Waste Streams
kg/day kg/yr
Aqueous Waste Streams
Contaminent flow kg/day Contaminent flow metric ton/yr Concentration (wt%)
UTILITY AND OFFSITES EMISSIONS
Vapor Emissions
Vapor Emissions
kg/day kg/yr Regulatory Status
Solid Waste Streams
kg/day kg/yr
Organic Waste Streams
kg/day kg/yr
Aqueous Waste Streams
Contaminent flow kg/day Contaminent flow metric ton/yr Concentration (wt%)
Company Name
Form XXXXX-YY-ZZ
EFFLUENT SUMMARY
PROCESS EMISSIONS
kg/day kg/yr Regulatory Status
Address

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