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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 Title V sources with only one responsible official, the permit application form may be used to designate the responsible official. However, when a change in responsible official is needed other than at the time of permit application, a Title V Source with only one responsible official shall submit this form to change the responsible official.
  • Each Title V source may designate more than one responsible official, provided a primary responsible official is designated on this 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 this form to the permitting authority, 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 and reason(s) for any replacements. Any previously-designated responsible official that is not included in the most recently submitted form will no longer be considered by the permitting authority or compliance authority to be a responsible official.
  • Each individual listed on this form must meet at least one of the responsible official qualifications listed on the form. The qualifications are based on the definition of “Responsible Official” given at Rule 62-210.200, F.A.C.
  • Multiple copies of page 2 of this form may be submitted as needed.
  • The completed 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:
April 27, 2023 - 2:57pm

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