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

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

FACILITY CONTACTS FORM

For new information on and updates to facility contacts

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



1. Purposeofsubmittingthisform



Thisformisbeingsubmittedto:

(Selectone)

Provideinformationonfacilitycontactsforanewfacility.

(Completeallsections)

Updateinformationoncurrentfacilitycontacts

(CompleteParts1,2,6andapplicablecontactsections)

2. FacilityName



FacilityName BAAQMD FacilityID(exceptnewfacilities)



3. Owner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. OperatorContact–Selectexistingcontactorfilloutinformationbelow.



SameasOwner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)







BAY AREA AIR QUALITY MANAGEMENT DISTRICT

FACILITY CONTACTS FORM

For new information on and updates to facility contacts

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 



5. Billing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)





6. 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:FacilityContactsForm



Introduction UsethefollowinginstructionstohelpguideyouthroughtheFacilityContactsform.



BayAre

aAirQualityManagementDistrict’snewcomputersystemrequiresallfacilities

havethreecontacts;ownercontact,operatorcontactandbillingcontact.Ifyouarean

existingfacility,untilyourcontactsareupdated,yourcurrentsitecontactwillbeused

asallthreecontacts.



Whoshoulduse

thisform?

Thisformisfor:

 Newfacilitiesthathavenocontactsassociatedwiththeirfacility.AFacility

Creation&Updateformmustalsobesubmitted.

 Existingfacilitiesthatneedtoupdateinformationoncontactsalready

associatedwiththefacility.



BAAQMD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.



ContactTypes OwnerContact–The individualrepresentingtheowner.Theowneristheindividual,

partnership,limitedliabilitycompany,corporation,orotherentitythatownsor

controlsthepermittedequipmentandisresponsibleforthepermittooperate.

OperatorContact–Theindividualresponsiblefordaytodayoperationsand/orair

qualityissuesatthefacility.

BillingContact–Theindividualresponsibleforpayinginvoices(accountsreceivable).

ThisindividualisthedefaultcontacttoreceiveallinvoicesfromBAAQMD.



E‐MailAddress BAAQMDisworkingonasystemwithonlinefeaturesandincreasedcommunication

throughe‐mail.Pleaseprovidee‐mailaddress(es),sothatwecaninformyouwhenthe

systemisavailable.



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



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