South Coast Air Quality Management District, Rule 109 Summary Report (2017.09)
Mail To:
SCAQMD
P.O. Box 4944
Diamond Bar, CA 91765-0944
Tel: (909) 396-3385
www.aqmd.gov
South Coast Air Quality Management District
Form 109-LVM
Low VOC Material Verification
Complete one form per facility.
Section D - Equipment Information
For facilities utilizing Rule 219 exemptions for all of the following categories:
Printing and reproduction equipment - Rule 219(h)(1)(E)
Coating and adhesive process equipment - Rule 219(l)(6)(F)
Drying Equipment - Rule 219(l)(11)(F)
The facility Responsible Official hereby verifies that for the calendar year
(Check all that apply):
All inks, coatings, adhesive, fountain solution, polyester resin and gel coat type materials, an associated VOC-containing
solvents (excluding clean up solvents) used in this equipment contain fifty (50) grams or less of VOC per liter of material;
and
All clean up solvents used in this equipment contain twenty five (25) grams or less of VOC per liter of material; and
The total annual quantity of VOC emissions from this equipment does not exceed one ton of emissions.
Rule 109 records, technical data sheets and other information are not required to be submitted, rather made available upon request.
There are no fees associated with this submittal.
Section E - Authorization/Signature I hereby certify that all information contained herein and information submitted with this application are true and correct.
7. Signature of Responsible Official:
8. Title of Responsible Official:
9. Print Name:
10. Date:
Section A - Operator Information
1. Facility Name (Business Name of Operator):
3. Owner’s Business Name (If different from Business Name of Operator):
2. Valid AQMD Facility ID
(Leave blank if a new business):
Section B - Equipment Location Address Section C - Business Mailing Address
4. Equipment Location Is:
Street Address
, CA
City Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail:
5. Correspondence Information:
Check here if same as equipment location address
Street Address
,
City State Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail:
