TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION 
 
                                                     CERTIFICATION OF POLLUTION CONTROL FACILITY 
 
   Use the same application for air, water, and hazardous waste pollution control equipment. (See “Instructions for Filing” on page 2.) 
   1.  Name of Company:                                                                                                                           
   2.  Contact Name:                                     Contact Phone:                 Contact Email:                                            
   3.  Mailing Address:                                                                                                                           
   4.  Property is in                      County, and located at:                                                                                
   5.  Identity of property as shown on county property tax records:                                                                              
                                                                                        PAGE NUMBER AND TAX BOOK NUMBER 
   6.  Purpose of facility: 
            Reducing air pollution       Reducing water pollution          Treating, Recycling or Disposal of Hazardous Waste 
 
       Please contact the Department of Revenue for information concerning a facility used for pollution control that does not fall within 
       one of the three categories listed. 
   7.  Date Installed:                   Date equipment placed in operation or intended to be in place for operation:                             
   8.  Provide a description of the appliances, equipment, machinery, or structure to be included in this certification. Reference 
       “Instructions for Filing” on page 2 for a listing of information required in this description.  If additional space is needed, please use 
       the attached blank form provided for you.                                                                                                   
 
   9.  Is the facility or equipment for which this certification is sought related to a process for production of a saleable commodity and/or 
       have a purpose other than pollution control?                               Yes       No 
       If yes, explain in detail the operation of the facility, the other purposes served, how much income will be derived from the sale of any 
       commodities produced from related processes before and after installation of the equipment of facility for which this certification is 
       sought and why the primary purpose of the facility is pollution control. If additional space is needed, use separate pages.                  
 
   10. Has the facility been registered with, or application for permit been made, to: 
 
       Division of Air Pollution Control   Yes       No         Division of Water Resources Yes           No 
 
       Division of Solid Waste Management            Yes  No    Was permit issued?      Yes No  Permit No. (if applicable):                        
   I hereby certify that the above described pollution control facilities are installed and operated, or intended to be installed and operated, 
   primarily for pollution control and in compliance with applicable laws. 
   Signed:                                                        Title:                                                                            
                  OWNER OR OFFICIAL 
 
                                                          Sworn to before                                                            , Notary 
       (Seal) 
                                                          Date                         My Commission expires on                                      

                                                     DO NOT WRITE BELOW THIS LINE                                                                     
 
   Allowed:                                                       Date Received:                                                       
 
   Allowed in part as reflected in attachments:                   Reviewed and Recommended By:                                         
 
   Disallowed:          
 
   Copy to        County Tax Assessor:                            Date:                                                                
 
   Copy to Owner:                                                 Date:                                                                
 
   This is to certify that in accordance with Tennessee Code Annotated section 67-5-604, the above described facility has been allowed in 
   whole or in part as a pollution control facility. 
 
   Name:                                                                Title:                                                         
 
   CN-0964 (Rev.08/19)                                                                                                   RDA SW01 

                                        Instructions for Filing 

                                 CERTIFICATION OF POLLUTION CONTROL FACILITY 

 For the certification of all pollution control facilities: 
 
 1.      Complete the form with original signatures and original notary. 
 
 2.      Please attach an itemized list of property to be certified, its description, its use and whether the purpose of the property is 
         considered reducing air pollution, reducing water pollution, or treating, recycling, or disposing of hazardous waste.  Please do 
         not itemize as a system or method instead of by item. One item in a system or method may qualify as a pollution control facility 
         whereas another item may not.  If an appropriate determination cannot be made due to inexact itemization, the application will 
         be denied.  Value of property is not certified by this department. 
 
 3.      For the following types of pollution control facility, please include the following in your description: 
 
         Reducing water pollution: Provide a detailed narrative describing how the facility or equipment for which certification is being 
         requested reduces water pollution and provide a schematic diagram and/or photos of the facility and its operation. If TDEC or a 
         local program has assigned a permit or tracking number for the facility, please be sure to include this number in both the form 
         and the narrative description. 
 
         Reducing air pollution: Provide a detailed narrative describing how the facility or equipment for which certification is being 
         requested reduces air pollution and provide a schematic diagram and/or photos of the facility and its operation. . If TDEC or a 
         local program has assigned a permit or tracking number for the facility, please be sure to include this number in both the form 
         and the narrative description. 
 
         Treating, recycling or disposing of hazardous waste: Provide a detailed narrative describing how the facility or equipment 
         for which certification is being requested treats, recycles, or disposes of hazardous waste and a schematic diagram and/or 
         photos of the facility. 
 
         For all divisions, the facility must be in use or intended for use, at the site on the date of submittal of the 
         application. 
 
 For all counties, except the counties listed below, applications should be emailed to Heather Weldon, Tennessee Department  
 of Environment & Conservation, Office of Policy & Sustainable Practices, at Heather.Weldon@tn.gov. 
 
 The Division of Water Resources, the Division of Solid Waste Management, and Division of Air Pollution Control (other than in 
 the counties noted below) will review and recommend certification, and the Tennessee Department of Environment and 
 Conservation (TDEC) will certify this to the appropriate county tax assessor. 
 
 For questions regarding the status of your Pollution Control Facility application, please contact Heather Weldon at (615)741- 
 8822 or heather.weldon@tn.gov. For questions regarding recognition of tax credits, please contact your local county tax 
 assessor. 
 
 Certification of Air Pollution Control equipment for Davidson, Hamilton, Knox, and Shelby Counties: 

 Davidson County:                       Hamilton County: 
 Metro Public Health Department         Chattanooga-Hamilton County Air Pollution Control Bureau 
 Air Quality Division                   6125 Preservation Drive, Ste. 140 
 2500 Charlotte Avenue                  Chattanooga, Tennessee 37416 
 Nashville, Tennessee 37209 
 
 Knox County:                           Shelby County: 
 Knox County Department of Air Quality  Memphis-Shelby County Health Department 
 140 Dameron Avenue, Ste. 242           Air Pollution Control Branch 
 Knoxville, Tennessee  37917            814 Jefferson Avenue 
                                        Memphis, Tennessee 38105 
 
 CN-0964 (Rev. 08/19)                                                                                             RDA SW01 

                        CERTIFICATION OF POLLUTION CONTROL FACILITY 
                        POLLUTION CONTROL EQUIPMENT LIST 
 
                                                                                    Original  For TDEC 
  County  Asset Number  Asset Description                            Date Acquired 
                                                                                    Cost      Use Only 
                                                                                              
 CN-0964 (Rev. 08/19)                                                                         RDA SW01