ࡱ>  Vbjbjqq ee+@g@gtttttuuu'w 3xuxL *3p?AAAAAA:At Att^---Ftt?-?--2߭r(*uŎ.+t0*\lt-AA-@g Is: Texas Commission on Environmental Quality Use Determination for Pollution Control Property Application A person seeking a use determination must complete this application form. For assistance in completing the application form please refer to the Instructions for Use Determination for Pollution Control Property Application Form TCEQ-00611, as well as the rules governing the Tax Relief Program in Title 30 Texas Administrative Code Chapter 17 (30 TAC 17). Information relating to completing this application form is also available in the TCEQ regulatory guidance document, Property-Tax Exemptions for Pollution Control Property, RG-461. For additional assistance, please call the Tax Relief Program at 512-239-4900. You must supply information for each field of this application form unless otherwise noted. Section 1. Property/Equipment Owner Information Company Name of Owner:  FORMTEXT       Mailing Address:  FORMTEXT       City, State, Zip:  FORMTEXT       Customer Number (CN):  FORMTEXT       Regulated Entity Number (RN): FORMTEXT       Is this property/equipment owned by the CN listed in Question 4? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  No, please explain:  FORMTEXT       Is this property/equipment subject to any lease or lease-to-own agreement? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  Yes, please explain:  FORMTEXT       Is this property/equipment operated by the RN listed in Question 5? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  No, please explain:  FORMTEXT       Section 2. Physical Location of Property/Equipment Name of Facility or Unit where the property/equipment is physically located:  FORMTEXT       Type of Mfg. Process or Service:  FORMTEXT       Street Address:  FORMTEXT       City, State, Zip:  FORMTEXT       County:  FORMTEXT       Appraisal District Account Number(s):  FORMTEXT       Section 3. Name of Property/Equipment Operator (If different from Owner) Company Name:  FORMTEXT       Mailing Address:  FORMTEXT       City, State, Zip:  FORMTEXT       Customer Number (CN):  FORMTEXT       Regulated Entity Number (RN): FORMTEXT       Section 4. Contact Name Company Name:  FORMTEXT       First Name of Contact:  FORMTEXT       Last Name of Contact:  FORMTEXT       Salutation: Mr.  FORMCHECKBOX  Mrs.  FORMCHECKBOX  Ms.  FORMCHECKBOX  Dr.  FORMCHECKBOX  Other:  FORMTEXT       Title:  FORMTEXT       Mailing Address:  FORMTEXT       City, State, Zip:  FORMTEXT       Phone Number/Fax Number:  FORMTEXT       Email Address:  FORMTEXT       Tracking Number (optional):  FORMTEXT       Section 5. General Information What is the type of ownership of this facility? Corporation  FORMCHECKBOX  Sole Proprietor  FORMCHECKBOX  Partnership  FORMCHECKBOX  Limited Partner  FORMCHECKBOX  Limited Liability Corporation  FORMCHECKBOX  Utility  FORMCHECKBOX  Other:  FORMTEXT       Size of Company: Number of Employees 1 to 99  FORMCHECKBOX  100 to 499  FORMCHECKBOX  500 to 999  FORMCHECKBOX  1,000 to 1,999  FORMCHECKBOX  2,000 to 4,999  FORMCHECKBOX  5,000 or more  FORMCHECKBOX  Business Description: (Briefly describe the type of business or activity at the facility)  FORMTEXT       Provide the North American Industry Classification System (NAICS) six-digit code for this facility.  FORMTEXT       Section 6. Property/Equipment Description, Applicable Rule, and Environmental Benefit For each piece, or each category, of pollution control property/equipment for which a use determination is being sought, answer the following questions. Attach additional response sheets to the application for each piece of integrated pollution control property/equipment if a use determination is being sought for more than one (1) piece. General Information Name the property/equipment:  FORMTEXT       Is the property/equipment used 100% as pollution control equipment? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  Yes, explain how it was determined that the equipment is used 100% for pollution control:  FORMTEXT       Does the property/equipment generate a Marketable Product? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  Yes, describe the marketable product:  FORMTEXT       What is the appropriate Tier I Table or Expedited Review List number?  FORMTEXT       Is the property/equipment integrated pollution control equipment? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  No, separate applications must be filed for each piece of property/equipment. List applicable permit number(s) for the property/equipment:  FORMTEXT       Incremental Cost Difference Is the Tier I Table percentage based on the incremental cost difference? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If the answer is  Yes, answer the following questions: What is the cost of the new piece of property/equipment?  FORMTEXT       What is the cost of the comparable property/equipment?  FORMTEXT       How was the value of the comparable property/equipment calculated?  FORMTEXT       Property/Equipment Description Describe the property/equipment. (What is it? Where is it? How is it used?)  FORMTEXT       Applicable Rule What adopted environmental rule or regulation is being met by the construction or installation of the property/equipment? The citation must be to the subsection level.  FORMTEXT       Environmental Benefit What is the anticipated environmental benefit related to the construction or installation of the property/equipment?  FORMTEXT       Section 7. Process Flow Diagram (Optional) Attach documentation to the application showing a Process Flow Diagram for the property/equipment. Section 8. Partial-Use Percentage Calculation This section must be completed for all Tier III applications. Attach documentation to the application showing the calculations used to determine the partial-use percentage for the property/equipment. Section 9. Property Categories and Costs List each piece of property/equipment of integrated pollution control property/equipment for which a use determination is being sought. 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NOTE: Separate applications must be filed for each piece of nonintegrated pollution control property/equipment. Section 10. Type of Application and Fee Type of Application being filed: Select only one. Tier I  Fee: $150  FORMCHECKBOX  Tier II  Fee: $1,000  FORMCHECKBOX  Tier III  Fee: $2,500  FORMCHECKBOX  Fee Payment Type: Check  FORMCHECKBOX  Money Order  FORMCHECKBOX  Electronic Payment  FORMCHECKBOX  Payment Receipt Number:  FORMTEXT       Payment Amount:  FORMTEXT       Payer Name on Payment:  FORMTEXT       Total Amount of Payment:  FORMTEXT       NOTE: Enclose a check, money order to the TCEQ, or a copy of the ePay receipt along with the application to cover the required fee. In accordance with the TCEQ s Delinquent Fee Protocol, the Tax Relief Program will not consider applications administratively complete until all delinquent fees the company owes to the TCEQ are paid. Information regarding the TCEQ s Delinquent Fee Protocol is available at: HYPERLINK "http://www.tceq.state.tx.us/agency/delin/index.html"http://www.tceq.state.tx.us/agency/delin/index.html. Section 11. Certification Statement Must be signed by owner or designated representative. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I further certify that the property/equipment listed in this application is eligible for a tax exemption under Texas Tax Code, 11.31 given that: the property/equipment is not solely used, constructed, acquired, or installed to manufacture or produce a good or provide a service, including a good or service that prevents, monitors, controls, or reduces air, water or land pollution, the environmental benefit associated with the property/equipment is not wholly derived from the use or characteristics of the goods or services produced by the property/equipment, the property/equipment is wholly or partly used, constructed, acquired, or installed to meet or exceed law, rule, regulation adopted by an environmental protection agency of the United States, Texas, or a political subdivision of Texas for the prevention, monitoring, control, or reduction of air, water, or land pollution, the property/equipment is not used for residential purposes, or for recreational, park, or scenic uses as defined by Texas Tax Code, 23.81, the property/equipment is not a motor vehicle, except for a dedicated service motor vehicle used solely for pollution control, and the property/equipment was not acquired, constructed, or installed before January 1, 1994. I am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Printed Name:  FORMTEXT       Date:  FORMTEXT       Signature: _______________________________________________ Title:  FORMTEXT       Company Name:  FORMTEXT       Under Texas Penal Code 37.10, if you make a false statement on this application, you could receive a jail term of up to one year and a fine up to $2,000, or a prison term of two to 10 years and a fine of up to $5,000. Application Submission Send the completed application and the appropriate fee, along with a complete copy of the completed application for the appraisal district, to: U.S. Mail Cashiers Office, MC 214 Tax Relief Program TCEQ PO Box 13088 Austin TX 78711-3088 Physical Address Cashier s Office, MC 214 Building A TCEQ 12100 Park 35 Circle Austin TX 78753     Use Determination for Pollution Control Property Application Form TCEQ-00611 May 2012 Page  PAGE 1 of  NUMPAGES 6 Use Determination for Pollution Control Property Application Form TCEQ-00611 March 2012 Page  PAGE 6 of  NUMPAGES 6 pppp qHq_VVVV $IfgdBy}kd*$$Ifl\4(#>b t044 laytywppppppppppppppqqqqq q"q6q8q:qDqFqHqJq^q`qtqvqxqqqqqqqqqqqβΤΠ晋zlzj.hywhsU jhywhvKUmHnHuj5.hywhsU hywhvKh%j-hywhsUj,hywhsUj,hywhsU hywh% jhywh%UmHnHujhywhsUj+hywhsU*HqJqqqqq_VVVV $Ifgdjkdy-$$Ifl\4(#>b t044 laytywqqqqqqqqqqqqqqqrrr*r,r.r8r:rrRrTrVr`rbrdrfrzr|r~rrrrrrrrrrrrrrrj+2hywhsUj1hywhsUj?1hywhsUj0hywhsUhvKj/hywhsU jhywhvKUmHnHuj!/hywhsU hywhvKjhywhsU0qrb t044 laytywrrrsBsjs_VVVV $IfgdBy}kd2$$Ifl\4(#>b t044 laytywrrrrrrrs s sssss0s2s4s>s@sBsDsXsZs\sfshsjslszs|sssssssssssstt*tβΤΠΒΠztnz h0J h 0Jh.h.0J hol0Jh.h0Jj5hywhsUhvKj4hywhsUjI4hywhsUj3hywhsU hywhvK jhywhvKUmHnHujhywhsUj]3hywhsU+jslszss_SJ $IfgdP $$Ifa$gdywkd55$$Ifl\4(#>b t044 laytywsst|uu0v2vvv.wRwTww{snnnninngdjgdj & F2gdjgd`gd8:ykdg6$$Ifl0(#~ t044 laytyw *t2t6t8t:tNtPttttzu|uuuuuuv v vv,v.vZv\vxvzv|v~vvvvvvvw w&w(w*w,w.w8wFwNwŶ͙͎͙{͙pj7hsUjm7hsUjhsUj6hsUjh`hsUhq~hq~0Jhq~h`0J hq~hq~hKhhq~h1~ h`h` ha0J2haha0J2hh. h0Jh.h.0J hvK0J,NwRwTw^wbwdwwwwwwwwwwwwwwwwwwwxxxxxx x0xRxTxhxjxlxvxxxxxxxxxrj/:h`hsUjh`h`Uj9h`hsUjh`hsUjE9hsUj8hsU h D h D jh D hsUjhsUjY8hsU hq~hq~jhq~hsUhq~h D h`h`,wwx x|xx"yyzz ||}}\~H$.6dgdqgdRĽĜtg\jhhsUhh8:B*aJphhh9XB*aJph hh o{hh~B*aJph hh CZhh@BDƔȔܔ "$ÿÿjhsU*h1GmHnHu*hsjhsUh hfh?j h8#h?jh?jhh?j0JPJhegjhegU hh$#hn heqhBh3h30J hphBhB7 "&(,.248:ؓBDPRTVgd8#LgdgdB$&(02HJLNPTV hh$#heghsh?jjhsUh1GmHnHu 5 01h:p</ =!"#$% 5 01h:pb/ =!"#$% U 01h:p|w"/ =!"#$% P0    5 01h:p1Z/ =!"#$% 9 01h:phzg/ =!"#$% P 9 01h:phzg/ =!"#$% P 5 01h:p`/ =!"#$% 9 01h:p</ =!"#$% P 5 01h:phzg/ =!"#$% 9 01h:p D / =!"#$% P 5 01h:phzg/ =!"#$% K 01h:p9X/ =!"#$% P0   5 01h:phzg/ =!"#$% 5 01h:pn/ =!"#$% 9 01h:pn/ =!"#$% P 9 01h:pn/ =!"#$% P tDText9vDText10vDText11vDText22vDText20vDeCheck33vDeCheck34vDText48vDeCheck35vDeCheck36vDText49vDeCheck37vDeCheck38vDText50vDText15vDText16vDText17vDText18vDText24&DText25,If not yet on Tax Roll, enter "New Property",If not yet on Tax Roll, enter "New Property"vDText12vDText13vDText14vDText23vDText20vDText27vDText28vDText29vDeCheck21vDeCheck22vDeCheck23vDeCheck24vDText26vDText30vDText31vDText32vDText33vDText34vDText21tDCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck10vDeCheck11tDText1vDeCheck12vDCheck13vDeCheck14vDeCheck15vDeCheck16vDeCheck17tDText2RDText3oSee http://www.census.gov/eos/www/naics/index.html to determine the most accurate NAICS code for your business.DText35Example: BaghouseExample: BaghousevDeCheck25vDeCheck26vDText36vDeCheck27vDeCheck28vDText37vDText38vDeCheck29vDeCheck30vDText39vDeCheck31vDeCheck32vDText40vDText41vDText42bDText43Example: The project installed internal floating roofs in storage tanks T-01 and T-02. 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