Form 3828 - Application For Air Pollution Control Tax Exemption Certificate Page 2
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5TE-EQUIPMENT
3828, Page 2
Application for Air Pollution Control Tax Exemption Certificate
Air Pollution Control Equipment Description.
May attach multiple TE-Equipment pages to one TE-Source.
PART 4: GENERAL INFORMATION
13. AQD Source ID (SRN)
14. Emission Unit
15. Describe the air pollution control equipment, the operational procedure, how it will minimize or control air pollution, and any function the equipment
serves that is other than for ambient air pollution control. Include non-air pollution control uses.
16. Permit Number/Permit Exemption Rule (must
17. Beginning Date of Construction
18. Projected/Completion Date of Construction
be provided)
For the equipment associated with the air pollution control that is claimed to be
PART 5: EQUIPMENT AND COST DETAILS.
exempt, provide a description, total cost, and the portion of the total cost being claimed as exempt for each of the items listed. If an
item does not exist, indicate "N/A." Provide plans and specifications for the facility, as an additional attachment, per Section 5902
(1). Provide an itemized list of equipment totaling the amount requested in box #7.
Total Cost of 19
19. Describe the air pollution control equipment (attach additional pages if necessary.
$
Costs must be separated into appropriate categories in 20-24).
Portion Claiming Tax Exempt (provide itemized list)
$
20. Describe the stack and specify other process/processes equipment associated with
Total Cost of 20
this stack.
$
Portion Claiming Tax Exempt (provide itemized list)
$
Total Cost of 21
21. Describe the ancillary equipment (foundations, enclosures, electrical equipment, etc.).
$
Portion Claiming Tax Exempt (provide itemized list)
$
Total Cost of 22
22. Describe the fans and motors. Distinguish between static pressure needed for the
plant's HVAC and process applications, and that needed for air pollution control
$
equipment.
Portion Claiming Tax Exempt (provide itemized list)
$
Total Cost of 23
23. Describe the ductwork and hoods including the percentage of ductwork necessary for
air pollution control purposes. (Do not include the percentage which is for the benefit of
$
personnel).
Portion Claiming Tax Exempt (provide itemized list)
$
24. Describe miscellaneous costs (engineering costs, administrative fees, feasibility study
Total Cost of 24
costs, etc.).
$
Portion Claiming Tax Exempt (provide itemized list)
$
25. Value of recovered product (must provide per Sec. 5902(2))
Total of 19-24
$
$
26. Is equipment replacing an existing piece of equipment already exempt?
Yes
No
If Yes, enter the Tax Exemption Certificate number ____________________________________
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