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Responsible Official Notification Form

Use this form to provide notification of Title V responsible official(s) as follows:

  • Each Title V source must identify a responsible official on each application for Title V permit, permit revision, and permit renewal. For sources with only one responsible official, the application form is used to designate the responsible official. However, the Responsible Official Notification Form shall be submitted by a Title V source for a change in responsible official.
  • Each Title V source may designate more than one responsible official, provided a primary responsible Official is designated on the Responsible Official Notification Form as responsible for the certifications of all other designated responsible officials. Any action taken by the primary responsible official shall take precedence over any action taken by any other designated responsible official.
  • Any facility initially designating more than one responsible official or changing the list of responsible officials must submit a Responsible Official Notification Form designating all responsible officials for a Title V source, stating which responsible official is the primary responsible official, and providing an effective date for any changes to the list of responsible officials.
  • Each individual listed on the Responsible Official Notification Form must meet at least one of the responsible official qualifications listed of the form.  The qualifications are based on the definition of "Responsible Official" given at Rule 62-210.200, F.A.C.
  • The completed Responsible Official Notification Form may be submitted electronically, but must be submitted to and the department's district office or contracted local program office that is the identified permitting authority for the Title V source.

Note:  A responsible official is not necessarily a "Designated Representative" under the Acid Rain Program.  To become a designated representative, submit a certificate of representation to the U.S. Environmental Protection Agency in accordance with 40 CFR Part 72.24.

Form Number: 
62-213.202, F.A.C.
Effective-Revision Date: 
Wednesday, August 17, 2022
Last Modified:
August 24, 2022 - 9:36am

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