Pre-Inspection Questionnaire (PIQ) - Connecticut
DEEP USE ONLY
Last Inspection: _________________
EPA Class: _____________________
Update: _________________________
Client: __________________________
Sequence: _______________________
Town: ___________________________
Premise: ________________________
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Pre-Inspection Questionnaire (PIQ)
Print or type unless otherwise noted. Please submit this completed questionnaire to 79 Elm Street, Hartford, CT 06106. If you have any
questions please contact us at (860) 424-3702 or by Fax at (860) 424-4082
Part 1: General Premises Information
|1. Company Name: |
|2. Premises Address: |
|City/Town: State: Zip Code: |
|3. Mailing Address (if different from premises address): |
|City/Town: State: Zip Code: |
|4. On Site Contact: Title: |
|Email Address: Phone Number: |
|5. Corporate Name: Date Owned: |
|6. Corporate Address (if different from premises address): |
|City/Town: State: Zip Code: |
|7. Corporate Contact: Title: |
|Business Phone: ext. Fax: |
|E-mail: |
|8. Nature of Operation: |
|SIC Code: NAICS Code: |
|9. Calendar year of date being submitted: |
Part 2: Process Information
DEEP CODE: Page of
Company Name:
|Emission Unit |Air Bureau Registration or New Source Review |Source Description |Vent ID |Dates of Installation, Last |Primary/Secondar|Typical |
|Number |Permit Numbers. Do not use Title V or GPLPE | | |Modification, and Removal from|y Air Pollution |Daily, Weekly and |
|(EMU#) |permit numbers | | |Service |Control System |Annual Hours of |
| | | | | | |Operation |
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Notes:
Part 4: Fuel Burning Sources
DEEP CODE: Page of
Company Name:
| |
|Emission |
|Unit |
|Number |
|(EMU#) |
| | | |
| | | |
|Authorized Signature | |Date |
| | | |
| | | |
| | | |
|Name of Signatory (print or type) |Title (if applicable) |
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