Notification of Compliance Status

							Notification of Compliance Status for Perchloroethylene Dry Cleaning Facilities
Each owner or operator of a dry cleaning facility shall submit to the EPA and Kansas Department of Health and
Environment by registered mail on or before July 28, 2008 a notification of compliance status providing the following
information. The notification shall be signed by a responsible official who shall certify the accuracy of the notification.
Submittal of this form will satisfy the requirements of '63.324(f) of 40 CFR Part 63 Subpart M.
Operator Information (Name and address of the owner or operator of the dry cleaning facility):
                                                                                                         (        )        -
     Name                                                                                                Phone Number


     Address


     City                                                                   State                             Zip Code
Address (physical location) of the dry cleaning facility:

     Name of the dry cleaning facility                                                                   BAR Source ID
                                                                                                         (        )       -
     Address of the dry cleaning facility (physical location)                                            Facility phone number


     City                                                                   State                             Zip Code
Is the perchloroethylene dry cleaning machine located in a building with a residence(s)?
Check yes even if the residence is vacant at the time of this notification.
(Check One)     Yes          No 
Is the perchloroethylene dry cleaning operation a major or area source?
                  Area         Major       (Major source: a facility with only dry-to-dry machines and a total yearly perchloroethylene
                                           consumption > 2100 gal. or a facility with only transfer machine systems or both dry-to-dry machine(s)
(Check One)      Source       Source       and transfer machine systems and a total yearly perchloroethylene consumption > 1800 gal. Area
                                         source: all perchloroethylene dry cleaning facilities that do not meet the definition of a major source)

Yearly perchloroethylene consumption:
                                         (Provide the sum of the volume of all perchloroethylene purchases made in the previous 12 months - i.e.
                           Gallons       the most recent Perc Consumption Running Total from your Dry Cleaning Compliance Calendar)

Is the perchloroethylene dry cleaning operation in compliance with each applicable requirement of
40CFR Part 63 Subpart M, '63.322?
Refer to the attached Subpart M Compliance Requirements Worksheet for compliance determination assistance.
(Check one) Yes           No 
Certification Statement: I certify under penalty of law that this document and all attachments were prepared under my direction
or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted. Based on information and belief formed after reasonable inquiry, including the person or persons who manage the system,
or those persons directly responsible for gathering the information, the stated information in this document is true accurate and
complete.


                Name of Responsible Official (Print or type)


                Signature of Responsible Official                                                             Date
Submit before July 28, 2008 by registered mail to:
     Richard Tripp                                                        Compliance and Enforcement Section
     Air Permitting and Compliance Branch                                 Bureau of Air and Radiation
     US EPA, Region 7                                   AND               Kansas Department of Health and Environment
             th
     901 N. 5 Street                                                      1000 SW Jackson Street, Suite 310
     Kansas City, KS 66101                                                Topeka, KS 66612-1366

                               For assistance or more information – contact SBEAP at 800-578-8898