Name of Owner or Operator __________

Address of Plant __________

Telephone Number (Plant) __________

Unit or Process __________

Type of Air Pollution Control Equipment __________

Supplier of Air Pollution Control Equipment __________

Schedule of Installation

Engineering Design Initiated (date) __________

Air Pollution Control Equipment Ordered (date) __________

Installation of Air Pollution Control Equipment Initiated (date) __________

Installation of Air Pollution Control Equipment Completed (date) __________

Start-up of Air Pollution Control Equipment (date) __________

(Attach copy of control equipment specifications and purchase order when order is placed or amended.)

(Signature)

(Title)

(Date)