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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|      |      |      |      |      |      |      |

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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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