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522637012.

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PERMIT APPLICATION FOR EXEMPTIONS

1. NON COMPLIANCE (for existing facilities only)

Provide the following information on non-compliance issues at the facility (add additional
lines if necessary)

Compliance Process/U Regulation/ Compliance Extent of BAT Compliance


Issue No nit Standard Issue non- Analysis Plan Reference*
Not Met compliance Reference*

* List the relevant section/ page numbers in the attachment

2. EXEMPTIONS (for existing facilities only)

Complete the following table (add additional lines if necessary)

Compliance Previously Measures Taken Reason for Justification* Final


Issue No Exempted to Address Exemption1 Compliance
Issue* Date
Yes No
Yes No
Yes No
1
Choose of the following: Technical, Hazardous/ Safety, Financial, Other
* List the relevant section/ page numbers in the attachment

M4-1
Facility: ______ Initials: ______

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