2. Only for unvented, dry-to-dry system equipped using perchloroethylene with emission control equipment that meets all requirements in 40 CFR 63, Subpart M
4. Agency Use Only
6. Date
7. Registration No.
8. Notification No.
12. Facility Information
14. Facility Name
15. Registration No.
17. Mailing Address
19. City
20. State
21. Zip Code
23. Installation Address
25. City
26. State
27. Zip Code
29. Is the dry cleaner located in a building with a residence?

    1. Yes
    2. No
31. Owner (if different than above)
33. Mailing Address
35. City
36. State
37. Zip Code
39. Contact Person
40. Email Address
42. Phone Number
43. Fax Number
45. Business Hours
46. Hours per Day
47. Days per Week
48. Weeks per Year
50. Estimated Installation Date
    Estimated Installation Date
52. If used machine, original installation date
    If used machine, original installation date
53. OR
54. Date machine manufactured
56. Estimated Annual Perchloroethylene Solvent Usage (gallons/year)
60. Equipment Information
62. Make
63. Model Number
64. Rated Capacity (pounds/load)
66. Type of Dry-to-Dry Machine (check one)

    1. Unvented machine with both a refrigerated condenser* and a secondary carbon adsorber**. Air-gas-vapor stream inside drum must pass through carbon adsorber before the machine door is opened.
    2. Unvented machine with a refrigerated condenser*
68. Attach any additional information about your machine that you'd like us to consider
70. * The refrigerated condenser must be designed to operate so temperature on the outlet side of the refrigerated condenser is 45 °F or less, as measured before the end of the cool down or drying cycle while the gas/vapor stream is flowing through the refrigerated condenser
    ** The carbon adsorber must be desorbed in accordance with manufacturer’s instructions
74. Certification
76. I, the undersigned, do hereby certify that the information contained in this notification is, to the best of my knowledge, accurate and complete.
78. Name
79. Phone Number
80. Date
    Date
82. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
84. Electronic Signature
86. You must pay a $200 filing fee to complete this application. Please select an option for payment below.

    1. Pay by Check (print a copy of this application and mail with check)
    2. Pay by Credit Card (an accounting technician will contact person listed below for payment information)
88. Contact Person for Credit Card Payment
89. Contact Phone Number
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit Submit and Print

* indicates a required field