Fill - Free fillable Device And Facility Shutdown Form (Bay Area Air Quality Management District) PDF form

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

DEVICE/FACILITY SHUTDOWN FORM

For surrendering permits by device or by facility

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



1. FacilityIdentification–Enterinformationasitappearsonyourpermit.



FacilityName BAAQMDFacilityID

 



2. Reasonforsubmittingthisform

Iamsubmittingthisformto:

(Selectone)

A.Shutdownsomedevice(s)attheabovefacilityB.Shutdownalldevicesatfacilityidentifiedabove



3. DeviceShutdown–Skipif2Bisselected.Attachseparatesheetifadditionalspaceisneeded.

Identifyalldevicesthathaveshutdownorwillbeshutdownatthisfacility.

BAAQMD

DeviceID

Dateof

Shutdown

(MM/DD/YYYY)

Dismantled?

(Yes/No)



BAAQMD

DeviceID

Dateof

Shutdown

(MM/DD/YYYY)

Dismantled?

(Yes/No)

   



Aftershutdownonthedate(s)provided,theowner/operatorhassurrenderedBAAQMDpermitsforthesedevices.Inorder

tooperateagain,theowner/operatormustapplyforandreceivenewpermits.Anyabatementdevicesidentifiedtobe

shutdownmustalsoshutdownthedevicesupstreamintheemissiontrain.Checkifyouunderstandthisstatement.



4. FacilityShutdown–Skipif2Aisselected.



Providethedatethefacilityidentifiedabovehasshutdownorwillshutdown.

DateofShutdown(MM/DD/YYYY)



Areallofthedevicesatthefacilitydismantledbytheaboveshutdowndate? Yes No

Aftershutdownonthedateprovided,theowner/operatorhassurrenderedtheirBAAQMDpermits.Inordertooperate

again,theowner/operatormustapplyforandreceivepermits.Checkifyouunderstandthisstatement.



5. 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1  v05/2016

Instructions:Device/FacilityShutdownForm



Introduction UsethefollowinginstructionstohelpguideyouthroughtheDevice/FacilityShutdown

Form.



ShuttingdownmeansthatthePermittoOperateforthedevice(s)orfacilityis

surrendered.Operationofanydeviceaftershutdownisnotallowed.Anewpermit

applicationmustbesubmittedandnewpermitsmustbeissued.



BAAQMDdoesnotrefundfeesfordevicesthatshutdownpriortopermitexpiration.



Whoshoulduse

thisform?

Thisformisfor:

 Declaringalldevicesatafacilityhaveorwillbeshutdown.

 Declaringspecificdevicesatafacilityhaveorwillbeshutdown.



BAAQMD

FacilityID

FacilityName–EnterthenameasitappearsontheBAAQMDpermitorinvoice.

BAAQMDFacilityID–ThefacilityIDisavailableonthepermitorinvoiceissuedby

BAAQMD.



Dismantled Dismantledmeansthedevicehaseitherbeenremovedorhasbeenphysicallychanged

sothatoperationisnotviable.Anexampleofaphysicalchangeisthefuellinefora

combustiondevicehasbeensevered.



Device

Shutdown

BAAQMDDeviceID – Thedevice IDisavailableonthepermitissuedbyBAAQMD.



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



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Device And Facility Shutdown Form (Bay Area Air Quality Management District)

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