Fill and Sign the Employee Progress Report Form

PERC DRY CLEANER STATUS UPDATE 1. Print or type the following information for EACH separately located dry cleaning facility. The owner of more than one facility should fill out a separate form for EACH facility. (Make additional copies of this form, if needed). Owner/Operator ____________________________________________________ Company Name ____________________________________________________ Mailing Address ____________________________________________________ Physical Address ____________________________________________________ City ____________________State___________Zip______County____________ Phone Number ______________________________________________________ 2. Initial Submission of Questionnaire Updated Submission of Questionnaire 3. Check the box below if: Your dry cleaner is a Pick-up Store. Your dry cleaning facility has only coin-operated dry cleaning machines that are operated by the customers. Your dry cleaning plant closed effective _________(date). If you checked any box above, you may STOP HERE and return the form to: ADEM-Air Division P. O. Box 301463 Montgomery, Al 36130-1463 4. Write in the total volume of perchloroethylene (PERC) purchased for ALL of the machines at the dry cleaning plant over the past 12 months. If your facility is new and has not operated an entire year, please estimate how much PERC will be purchased in the next 12 months: _____Gallons (Actual or Estimated) ADEM Form 436 11/12 m1 Page 1 of 3 5. Indicate the number of machines of each type that is located at your facility: ______Dry-to-Dry _________Transfer 6. Are records of perceptible leaks, parts ordered, repairs, refrigerated condenser temperature monitoring, PERC purchases, etc., being kept? Yes No (If no is checked, these records are a requirement. Your facility should begin keeping these records. They should be kept for five years and be readily available for inspection). 7. Are you using the 20__ Dry Cleaner Compliance Calendar for recordkeeping? Yes No 8. Provide the following information for EACH MACHINE at your plant. If you have more than 4 machines at your plant, make additional copies of this form. Machine 1 Machine Type Dry-to-Dry (Circle one) Transfer Date Machine was installed Control Device (refrigerated condenser or carbon adsorber) Date Control Device was installed Machine 2 Machine 3 Machine 4 Dry-to-Dry Transfer Dry-to-Dry Transfer Dry-to-Dry Transfer 9. If there has been a change in ownership at this facility in the past 12 months, please indicate below. ____________________________ Name ___________________________ Date 10. Has there been a change from PERC to another cleaning agent? Yes No If so, indicate the type of cleaning agent and date of changeover. _______________ ADEM Form 436 11/12 m1 Page 2 of 3 11. Print or type the name and title of the Responsible Official for the dry cleaning plant: Name Title Signature Date Please return this form to: ADEM-Air Division, P. O. Box 301463, Montgomery, Al 36130-1463 ADEM Form 436 11/12 m1 Page 3 of 3