South Coast Air Quality Management District, Form 200-C (2014.07)
Mail To:
SCAQMD - Permit Services
P.O. Box 4944
Diamond Bar, CA 91765-0944
Tel: (909) 396-3385
www.aqmd.gov
South Coast Air Quality Management District
Form 200-C
Request To Inactivate A Permit To Operate
AQMD
USE
ONLY
15. Signature of AQMD Inspector (Optional):
16. Date:
17. Print Name:
18. Phone #:
Section A - Permit Information
1. Facility Name (Business Name of Operator As It Appears On The Permit): 2. Valid AQMD Facility ID (Available On Permit Or Invoice Issued By
AQMD):
3. Permit Number:
4. Date Issued:
5. Equipment Description:
Section B - Equipment Location Address Section C - Permit Mailing Address
6. Fixed Location Various Location
(For equipment operated at various locations, provide address of initial site.)
Street Address
, CA
City State Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail
7. Permit and Correspondence Information:
Check here if same as equipment location address
Address
,
City State Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail
It is understood that any future use of this equipment may require a new permit application in accordance with the laws then in effect.
Section D - Reason for Inactivation
8. Cancellation of the Permit to Operate described above is hereby requested for the following reason(s):
Equipment Sold Destroyed or Removed from site. Effective Date:
Equipment was replaced. New Permit Number:
Equipment will no longer be operated. Date Operation Ended:
Equipment is exempt from permit requirements by AQMD Rule 219. Indicate Rule Section:
Business & Equipment Sold. Effective Date:
Name and Address of new owner:
Name:
Address:
Contact:
Phone #:
Other (explain):
I hereby certify that all information contained herein and information submitted with this application is true and correct.
9. Signature of Responsible Official:
10. Title of Responsible Official:
11. Print Name of Responsible Official:
12. Date:
13. Phone #:
14. Fax #:
Section E - Authorization/Signature
