FORM D4

FORM D4 EXEMPT AND INSIGNIFICANT ACTIVITIES SUMMARY REVISED 09/22/16

NCDEQ/Division of Air Quality - Application for Air Permit to Construct/Operate

ACTIVITIES EXEMPTED PER 2Q .0102 OR INSIGNIFICANT ACTIVITIES PER 2Q .0503 FOR TITLE V SOURCES

DESCRIPTION OF EMISSION SOURCE

SIZE OR PRODUCTION RATE

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Attach Additional Sheets As Necessary

BASIS FOR EXEMPTION OR INSIGNIFICANT ACTIVITY

D4