Fill - Free fillable Application Cover Form (Bay Area Air Quality Management District) PDF form

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

PERMIT APPLICATION COVER FORM



All fields are required unless otherwise noted. Please type or print.

Mail to:

BAAQMD

Engineering Division

375 Beale St., Suite 600

San Francisco, CA 94105



 Tel:(415) 749-4990

Page1of2 Anelectronicversionofthisformandinstructionscanbefoundatwww.baaqmd.gov. v05/2016 



 Thisformmustbesubmittedwithallpermitapplicationpackages.

 NewfacilitiesmustsubmitaFacilityCreationFormandFacilityContactsFormwiththisPermitApplicationCover

Formandanyotherpermitapplicationforms.



1. ApplicationTitle–Forregistrations,donotusethisform.Applyonlineatwww.baaqmd.gov



ApplicationTitle



ProjectDescription(Optional)



2. FacilityIdentification



FacilityName BAAQMDFacilityID(Existingfacilitiesonly)



3. ApplicationContact‐Selectexistingcontactorfilloutinformationbelow.

 SameasOwnerContact SameasOperatorContact

FirstName LastName



BusinessNameofContact(Ifdifferentfromfacility) ContactTitle



AddressLine1 AddressLine2(Optional)



City State ZipCode

 

E‐mailAddress



PrimaryPhone(xxx‐xxx‐xxxx) AlternatePhone(optional) FaxNumber(Optional)





4. SmallBusiness&GreenBusinessCertifications(Optional)

SmallBusinessEligibility–Thissectiondoesnotapplytogasdispensingfacilities.

DoesthefacilityidentifiedinPart2above:

Employ10employeesorless?

Yes No

Haveagrossannualincomelessthanorequalto$750,000?

Yes No

Affiliatedwithanothercompany?

Yes No

Ifyes,doestheaffiliatedcompanyemploy10employeesorless?

Yes No

Ifyes,doestheaffiliatedcompanyhaveagrossannualincomelessthanorequalto$750,000?

Yes No

GreenBusinessCertification

IsthefacilityidentifiedinPart2abovecurrentlycertifiedundertheBayAreaGreenBusinessProgramascoordinatedbythe

AssociationofBayAreaGovernmentsandimplementedbyparticipatingcounties?

Yes No Ifyes,submitacopyofthecurrentGreenBusinessCertification.



5. ProximitytoaK‐12School

Areanyofthedevicesinthispermitapplicationwithin1,000feetoftheouterboundaryofaschool,whereaschoolis

definedaskindergartenthroughGrade12?

Yes No





BAY AREA AIR QUALITY MANAGEMENT DISTRICT

PERMIT APPLICATION COVER FORM



All fields are required unless otherwise noted. Please type or print.

Mail to:

BAAQMD

Engineering Division

375 Beale St., Suite 600

San Francisco, CA 94105



 Tel:(415) 749-4990

Page2of2 Anelectronicversionofthisformandinstructionscanbefoundatwww.baaqmd.gov. v05/2016



6. CEQA–Ifyestoeitherquestionbelow,completeandsubmittheCEQAworksheetattheendofthisform.

A. Hasanotherpublic/regulatoryagencyprepared,requiredpreparationof,orissuedanoticeregarding

preparationofaCaliforniaEnvironmentalQualityAct(CEQA)document(initialstudy,negativedeclaration,

environmentalimpactreportorotherCE

QAdocument)thatanalyzesimpacts

ofthisprojectoranother

projectofwhichitisapartortowhichitisrelated? Yes No



B. Arethereanyotherprojects,priororcurrent,forwhicheitherofthefollowingstatementsistrue?

 Theprojectthatisthesubje

ctofthisapplicationcouldnotbeundertaken

withouttheotherproject(s),

 Theotherproject(s)cannotbeundertakenwithouttheprojectthatisthesubjectofthisapplication.

Yes No



7. ApplicationBillingContact‐Selectexistingcontactorfilloutinformationbelow.

 SameasOwnerContact SameasOperatorContact SameasBillingContact



FirstName LastName



BusinessNameofContact(Ifdifferentfromfacility) ContactTitle



AddressLine1 AddressLine2(Optional)



City State ZipCode

 

E‐mailAddress



PrimaryPhone(xxx‐xxx‐xxxx) AlternatePhone(optional) FaxNumber(Optional)





8. Certification/Signatureofpersonresponsiblefortheinformationonthisform.

IherebycertifythatIamauthorizedtocompletethisformforthefacilityandthatallinformationcontainedhereinistrue

andcorrect.

Name Title



Signature Date Phone(xxx‐xxx‐xxxx)

 



BAY AREA AIR QUALITY MANAGEMENT DISTRICT

CEQA Worksheet

Required if answered “Yes” to either question in Part 6 of Permit Application Cover form.



Mail to:

BAAQMD

Engineering Division

375 Beale St., Suite 600

San Francisco, CA 94105



All fields are required unless otherwise noted. Please type or print. Tel:(415) 749-4990

Page1of1 Anelectronicversionofthisformandinstructionscanbefoundatwww.baaqmd.gov. v05/2016



1. CEQADocumentation(SkipifyouansweredNOtoPart6AonPermitApplicationcoverform.)

DocumentorNoticeType(Chooseone)

EnvironmentalImpactReport InitialStudy NegativeDeclaration



NoticeofCompletion NoticeofDetermination NoticeofExemption

 NoticeofPreparation Other(specify):



DateofDocument/Noticeor

ExpectedDateofCompletion

ElectronicLinktodocument,ifavailable(e.g.,http://www.example.com)



LeadAgencyName LeadAgencyContactName



LeadAgencyContactPhone(xxx‐xxx‐xxxx) LeadAgencyContactE‐mailAddress,ifavailable



Ifnotavailableonline,submitacopyofallavailabledocumentationwiththisworksheet.



2. RelatedProjects(SkipifyouansweredNOtoPart6BonPermitApplicationcoverform.)

Listanddescribeallotherpriororcurrentprojectsthatarerelatedtotheprojectthatissubjecttothisapplication.



NameofRelatedPriororCurrentProject BAAQMDApplication#(ifapplicable)



DescriptionofRelatedProject



NameofRelatedPriororCurrentProject BAAQMDApplication#(ifapplicable)



DescriptionofRelatedProject



NameofRelatedPriororCurrentProject BAAQMDApplication#(ifapplicable)



DescriptionofRelatedProject



3. Certification/Signatureofpersonresponsiblefortheinformationonthisform.

IherebycertifythatIamauthorizedtocompletethisformforthefacilityandthatallinformationcontainedhereinistrue

andcorrect.

Name Title



Signature Date Phone(xxx‐xxx‐xxxx)

 



BAYAREAAIRQUALITYMANAGEMENTDISTRICT

BAAQMD

EngineeringDivision

375BealeSt.,Suite 600

SanFrancisco,CA94105



Page1of2  v05/2016

Instructions:ApplicationCoverFormandCEQAWorksheet



Introduction UsethefollowinginstructionstohelpguideyouthroughtheApplicationCover form

andCaliforniaEnvironmentalQualityAct(CEQA)Worksheet.



Whoshoulduse

these

documents?

TheApplicationCoverform isrequiredforallpermi

tapplicationrequests,including

butnotlimitedto:

 Newdevices/operationsincludingreplacements

 Modifyexistingdevices/operations

 Changepermitcondition

IfyourapplicationtriggersCEQA,thentheCEQAWorksheetisrequired.



Application

Type&Title

ApplicationTitle‐Provideatitlethatidentifiesthisapplication.



Facility

Identification

BAAQMDFacilityID ‐ Ifyouareanexistingfacility,fillthe facilityIDisavailableon

yourpermitorinvoiceissuedbyBAAQMD.

 Ifthisapplicationisforanewfacility(notcurrentlypermittedbyBAAQMD),

youmustalsosubmitaFacilityCreationandFacilityContactsforms.



Application

Contact

Identifyacontactforthispermitapplication.Thisisthepersonthatwillberesponsible

forthepermitapplicationduringprocessing.

 Forexistingfacilities,youmayuseanexistingOwnerorOperatorcontact,

whichareavailableonyourpermitissuedbyBAAQMD.Ifyourpermitwas

issuedbeforeMarch5,2012,thepersonidentifiedasthepermittedoperator

wasdesignatedtobethedefaultcontactinthenewsystem.Toupdatethese

contacts,submitaFacilityContactsform.

 Fornewfacilities,yourcontactswouldbeidentifiedonyourFacilityContacts

Form.



SmallBusiness

&Green

Business

Certifications

Thissectionisoptional.Thequestionsrefertothefacilitythatthepermitswillbe

issuedto,notanythirdpartyfillingouttheformsonbehalfofthefacility.



SmallBusinessquestions–Thissectiondoesnotapplytogasdispensingfacilities.



Proximitytoa

K‐12School

Youarerequiredtoidentifywhetherthedevices/operationsinthepermitapplication

(specificallytheemissionpoints/outlets)arewithin1000feetoftheouterboundaryof

akindergartenthrough12

gradeschool.Suggestedonlineplacestofindschool

locationsarewww.greatschools.netorschoollocatorusingGoogleEarth.



BAYAREAAIRQUALITYMANAGEMENTDISTRICT

BAAQMD

EngineeringDivision

375BealeSt.,Suite 600

SanFrancisco,CA94105



Page2of2  v05/2016

California

Environmental

QualityAct

(CEQA)

Question6B

Thisistoidentifywhetherthisapplicationisasmallerpartofalargerprojectthatcould

triggerCEQAwhenconsideredasawhole.



Application

BillingContact

Identifyabillingcontactforthispermitapplication.

 Forexistingfacilities,youmayuseanexistingOwnerorOperatorcontact,

whichareavailableonyourpermitissuedbyBAAQMD.Ifyourpermitwas

issuedbeforeMarch5,2012,thepersonidentifiedasthepermittedoperator

wasdesignatedtobethedefaultbillingcontact.Toupdatethesecontacts,

submitaFacilityContactsform.

 Fornewfacilities,yourcontactsareidentifiedonyourFacilityContactsForm.



CEQA

Documentation

LeadAgency–Theprimaryauthoritytoimplementorapproveaproject,suchaswhen

itadoptsairqualityplansfortheregion,issuesstationarysourcepermits,oradopts

rulesandregulations.



RelatedProjects IftherelatedprojectswerealsosubmittedasseparateBAAQMDpermitapplications,

providetheApplicationnumberasitwasassigned.Thenumberwasalsoprovidedon

theAuthoritytoConstructpermitifitwasissued.



Stillneedhelp? CalltheEngineeringDivisionat(415)749‐4990.



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