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

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

FACILITY CREATION FORM

For new facilities or facilities not currently permitted by BAAQMD

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 

 AFacilityContactsFormmustalsobesubmittedwiththisform.



1. FacilityName



FacilityName



2. OwnershipandBusinessType



OwningEntity



TypeofBusiness(Selectone)

 Corporation Partnership Soleproprietorship

 Federalgovernment Stategovernment Localgovernment



3. FacilityPhysicalAddress/Location

 Thisfacilitydoesnothaveastreetaddress.Ifchecked,submitmapwithlocationmarked.(Seeinstructions)



StreetAddressorIntersectionorNearestStreet



AddressLine2(Optional)



City State ZipCode

 CA 



4. NorthAmericanIndustryClassificationSystemCode

Enteryourfacility’sprimaryNAICScode.

NAICSCode(6digits)



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)

 



BAAQMDOfficeUseOnly–Skipthissection



BAAQMDFacilityID



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 Creation Form

Introduction

Use the following instructions to help guide you through the Facility Creation form.

You must submit a Facility Contacts form as well as this form.

Who should use

this form?

This form is for:

 New facilities, not previously permitted by BAAQMD at that location/address.

 Currently permitted facilities that will be changing locations. BAAQMD permits

are not transferrable. A new permit application is required.

 If applicable, submission with the Transfer of Ownership form. See

instructions

Owning Entity &

Type of

Business

Owning Entity - 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. If no fictitious name is used, the owner can be the same name as the

facility name above.

Type of Business

A partnership is an association of two or more persons to carry on as co-owners.

A sole proprietorship is owned and run by one individual and in which there is no legal

distinction between the owner and the business.

Facility Physical

Address

If your facility does not currently have a physical address, enter a cross street or nearest

street along with the city and zip code. Submit a map, outlining the physical boundaries

of your property in addition to the form.

North American

Industry

Classification

System code

North American Industry Classification System (NAICS) is the standard used by Federal

statistical agencies in classifying business establishments for the purpose of collecting,

analyzing, and publishing statistical data related to the U.S. business economy. This

code represents the primary operation of your business, NOT the primary device

permitted by BAAQMD.

Below are common NAICS codes:

811121

Automotive Body, Paint, and Interior Repair and Maintenance

812320

Dry Cleaning and Laundry Services (except Coin‐Operated)

447110

Gas dispensing facility with Convenience Stores

447190

Gas dispensing facility without Convenience Stores

Still need help?

Call the Engineering Division at (415) 749-4990.

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