[EPD Permit Engineer]
Environmental Engineer
Stationary Source Permitting Program
Georgia EPD - Air Protection Branch
4244 International Parkway, Suite 120
Atlanta, Georgia 30354

Re: Permit No. XXXX-XXX-XXXX-V-XX-X
Off-Permit Change

Dear [Mr./Ms. EPD Permit Engineer]:

[Company Name] has made the following change pursuant to Georgia Air Quality Control Rule 391-3-1-.03(10)(b)6.

1) Description of the change: [insert description of change]

2) Date of the change: [insert date of change]

3) Pollutant(s) emitted: [insert pollutants emitted from source(s) being changed]

4) Change in emissions: [insert increase or decrease in emissions due to change]

5) Applicable requirements that apply as a result of the change: [indicate applicable requirement(s)]

This change meets all applicable requirements, does not violate any existing permit term or condition, and does not constitute a title I modification.

Based on information and belief formed after reasonable inquiry, the statements and information in the document are true, accurate, and complete.

Sincerely,

[Name of "Responsible Official" for Title V]
[Title of "Responsible Official"]

cc: U.S. EPA Region 4
Operating Source Section
Air and Radiation Technology Branch
61 Forsyth Street
Atlanta, Georgia 30303