Poultry Continuous Release Report Form Page 3
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4Poultry EPCRA ‘Continuous Report’ Form
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Report of Release:
__________ (Date report is filled out and sent)
1. Type of Report:
Continuous Emission Report for Ammonia released from Chicken Manure
Initial Written Report
Written notification of a change
2. Signed Statement:
I certify that the substance releases described herein are continuous and stable in quantity and rate under
the definitions in 40 CFR 302.8(a) or 355.40(a)(2)(iii) and that all submitted information is accurate and
current to the best of my knowledge.
Print: Name and Position:
_____________________________________________
Date:
_______________
Signature:
________________________________
3. Facility Information
Facility Name(s)*:
Name of person in charge and position:
Phone Number:
_______________
4. Facility Location
Street*:
County: ______________
City
State
Zip Code
* Regardless of different farm accounts/names, if the houses on your farm are on a contiguous piece of
property under common ownership, they are considered one facility and all birds on the farm must be
counted toward the threshold.
Type of operation:
Broilers [ ]
Layers [ ]
Type of waste handling:
non-Liquid manure handling [ ]
Liquid manure handling [ ]
Maximum chicken population onsite: ___________________ # of poultry houses: ______________
If you use non-liquid manure handling and have equal to or greater than 125,000 broilers or 82,000
layers, or use liquid manure handling and have equal to or greater than 30,000 chickens, you are
covered by this requirement and must complete the remainder of this form. If not, stop here and send
this form as a record that you are exempt.
5.
Facility Latitude
Facility Longitude
(You can put your address into ‘maps.yahoo.com’ or ‘google earth’ to obtain your Latitude and Longitude)
6.
Dun and Bradstreet Number for Facility _________________ (only if available)
7. Population: Choose range that best describes population density within a one-mile radius of your facility
[ ] 0-50 persons [ ] 51-100 persons
[ ] 101-500 persons
[ ] 501-1000 persons
[ ] over 1000
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