South Coast Air Quality Management District, Form 200-A (2014.07)
Mail To:
SCAQMD - Permit Services - Data Entry
P.O. Box 4944
Diamond Bar, CA 91765-0944
Tel: (909) 396-3385
www.aqmd.gov
South Coast Air Quality Management District
Form 200-A
Business Name Change
AQMD
USE ONLY
APPLICATION TRACKING # CHECK #
AMOUNT RECEIVED
$
PAYMENT TRACKING #
VALIDATION
DATE APP
REJ
DATE APP
REJ
CLASS
I III
BASIC EQUIPMENT CATEGORY CODE
CONTROL
TEAM
ENGINEER
REASON/ACTION TAKEN
This is a notification to the South Coast Air Quality Management District that the name of our business has
been changed. This is for a change of NAME ONLY and NOT a Change of Operator. We understand
new applications must be filed with the South Coast Air Quality Management District for each piece of
equipment being operated by us for any change in the operator (Form 400-CO and Form 400-CEQA) or
location (Form 400-A and Form 400-CEQA) of our business.
I understand that each permit at this facility must be reissued with the new business name and
that a reissue fee applies for each permit as per Rule 301. (Different fees apply to Title V and
RECLAIM facilities as per Rule 301.)
Section A - Request To Update/Correct Business Name of Operator
1. Current Facility ID:
2. Equipment Location:
Street Address
, CA
City State Zip
3. Old Business Name of Operator:
4. Correct/New Business Name of Operator:
5. Provide a copy of a legal document(s), such as, tax ID certificate or business license showing that this is a name change only.
6. List the application OR permit
numbers to be reissued:
(See Rule 301 for current reissue fees.)
Section B - Authorization/Signature
I hereby certify that all information contained herein and information submitted with this application is true and correct.
7. Signature of Responsible Official:
8. Title of Responsible Official:
9. Print Name:
10. Date:
11. Phone #:
12. Fax #:
AQMD USE ONLY
Documents received:
Verified by Compliance Staff: Date:
