Emissions Inventory Forms

For Calendar Year 2008

If your business is required to report emissions to APCD, please use the forms below. See form SAM 1 for general instructions.  The forms are available in PDF format and either WordPerfect 6.x-10 format or Microsoft Word 97-2003 format. To save a document to your computer, right-click on the link and choose "Save Target As" or "Save Link As" (depending on your browser software).

With the exception of filling in the requested information, these forms must be submitted without modification.

Title of Document PDF WordPerfect or MS Word
Forms Identification SAM 1 (PDF) SAM 1 (WP)
General Reporting Instructions SAM 2A (PDF) SAM 2A (WP)
Petroleum Product Bulk Terminals Special Instructions SAM 2B (PDF) SAM 2B (WP)
Paint Manufacturing Operations Special Instructions SAM 2C (PDF) SAM 2C (WP)
Abbreviations and Acronyms SAM 3 (PDF) SAM 3 (WP)
Definitions SAM 4 (PDF) SAM 4 (WP)
Non-VOC Organic Compounds List SAM 5 (PDF) SAM 5 (WP)
HAP Classifications SAM 6 (PDF) SAM 6 (WP)
Annual Boiler Fuel Usage Survey SAM 20 (PDF) SAM 20 (WP)
Annual Process Fuel Usage Survey SAM 21 (PDF) SAM 21 (WP)
Hazardous Air Pollutant Emissions Reporting Form SAM 30 (PDF) SAM 30 (WP)
HAP Emissions Reporting Form for Boilers and Combustion Units SAM 35 (PDF) SAM 35 (WP)
Particulate Data SAM 40A (PDF) SAM 40A (WP)
Particulate Matter (PM10) Data SAM 40B (PDF) SAM 40B (WP)
Particulate Matter (PM2.5) Data SAM 40C (PDF) SAM 40C (WP)
Particulate Matter - Wet Cooling Towers SAM 40D (PDF) SAM 40D (WP)
VOC, Use/Composition SAM 50A (PDF) SAM 50A (WP)
VOC, Drycleaners SAM 50B (PDF) SAM 50B (WP)
VOC, Small Sources SAM 50C (PDF) SAM 50C (WP)
VOC, Petroleum Products SAM 50D (PDF) SAM 50D (WP)
VOC, Automotive Body, Paint and Interior Repair SAM 50E (PDF) SAM 50E (WP)
Stage II Gasoline Dispensing Facilities - Monthly Throughput Form SAM 50F (PDF) SAM 50F (Word);
SAM 50F (WP)
Stage I Gasoline Dispensing Facilities - Monthly Throughput form - due April 15. Stage I Throughput Form (PDF) Stage I Throughput Form (Word)
Category 1 Toxic Air Contaminant (TAC) Enhanced Emission Data. (SAM 81) - not required at this time.
Insignificant Activities Summary Insignificant Activities Form (PDF) Insignificant Activities Form (WP)
Pollutant Summary and Certification SAM 99D (PDF) SAM 99D (WP)
 

Compliance Certification Forms

These forms can also be found as part of the permit application forms packets on the permit forms page.

Permit Type

PDF

WordPerfect or MS Word

Title V 9400-O (PDF) 9400-O (WP)
FEDOOP 9420-O (PDF) 9420-O (WP)
NESHAP - 40 CFR 63 part HHHHHH NESHAP- HHHHHH (PDF) NESHAP- HHHHHH (MS Word)

 

Useful Documents and Links

If you have trouble opening a file by clicking the link, try this: Download the file (on most browsers, right-click and choose "Save Target As" or "Save Link As") and open it with the appropriate program (Adobe Reader, WordPerfect or Microsoft Word).  For documents in Adobe Acrobat format, depending on the availability of fonts, the equations and special characters may not display properly on the screen or printer.