Schedule 12
Air Quality Regulations (2001)
ANNUAL AIR EMISSIONS SUMMARY REPORT
FACILITY NAME: _______________________
Licence No: yySSnnn
REPORTING YEAR (January 1 to December 31), ________
This summary report is required for satisfying conditions of licences. The
information will be used to determine and adjust emission fees if necessary for
the reporting year and also will be used to compile a national air pollutant
emission inventory.
Plant information
Plant name
___________________________
Plant mailing addressLine1: ___________________________
Plant mailing addressLine2: ___________________________
Plant mailing addressLine3: ___________________________
Plant Activity
Days of week operating
Thu
Fri
Sat
Sun
Mon
Tue
Wed
Hours per day
Months operating and approximate percentage of annual emissions in each month
J
N
F
M
A
M
J
D
Days per year facility operated: ___________
J
A
S
O
ANNUAL AIR EMISSIONS SUMMARY REPORT: YEAR _________
FACILITY NAME: _______________________
Licence No: yySSnnn
Fuel information
Fuel Type
Heavy fuel oil (No.5 or
6)
Heavy fuel oil (No 5
or 6 or Low
Vanadium)
Coal
LPG
Kerosene
Marine Diesel
Autodiesel*
Gasoline
(unleaded) *
Gasoline (leaded)
*
Bagasse
Fuel wood
Charcoal
Other (specify)
Other (specify)
Other (specify)
Associated Annual
SCCs
use
(Metric
units)
Average Average Average Average
Heat
%
% Ash Density
content Sulphur
ANNUAL AIR EMISSIONS SUMMARY REPORT: YEAR ______________
FACILITY NAME: _______________________
Licence No: yySSnnn
Raw Materials Used for year
(Include only those necessary for use with emission factors)
Raw Material
Annual use How stored How moved
ANNUAL AIR EMISSIONS SUMMARY REPORT:
YEAR
____
FACILITY NAME: _______________________
Licence No: yySSnnn
Products
(Include only those necessary for use with emission factors)
Product
Actual
How stored How shipped
Annual
Production
SUMMARY OF ANNUAL ACTUAL EMISSIONS INFORMATION
FOR REGULATED POLLUTANTSAND GREENHOUSE GASES
REPORTING YEAR (January 1 to December 31), ________
Total actual air pollutant emission information during normal operation, plant startup,
shut down and malfunction and all other operating conditions.
Repeat Table for additional sources as needed
Source ID#
Source name
Associated process ID(s)
Type of source (point (P), area (A),
off road mobile (ORM))
Stack height from ground (m)
Area source length (m)
Area source width (m)
Area source direction (angle long
axis is offset from north-south)
Six-digit Location UTMN
Six-digit Location UTME
Actual annual emissions for each
pollutant and basis of estimate (1)
ST EF MB Other
SO2
TSP
PM10
Nox
CO
VOC
Pb
Summary of Greenhouse Gas Emissions
CO2
N2O
CH4
HFCs
PFCs
SF6
(1) Place a check mark to indicate method used. ST Stack test data; EF Emission factor; MB
Mass balance, Other - Specify method used in an attachment.
SUMMARY OF ANNUAL ACTUAL EMISSIONS INFORMATION
PRIORITY AIR POLLUTANTS
REPORTING YEAR (January 1 to December 31), ________
Total actual priority air pollutant emission information during normal operation,
plant startup, shut down and malfunction and all other operating conditions.
Repeat Table for additional sources as needed
Source ID#
Source name
Associated process ID(s)
Type of source (point, area, off
road mobile)
Stack height from ground (m)
Area source length (m)
Area source width (m)
Area source direction (angle long axis
is offset from north-south)
Six-digit Location UTMN
Six-digit Location UTME
Actual annual emissions for each
priority air pollutant identified by
CAS Number (1)
ST EF MB Other
(1)
Place a check mark to indicate method used. ST Stack test data; EF Emission factor; MB Mass balance,
Other - Specify method used in an attachment