South Coast Air Quality Management District, Form 400-A (2014.07)
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 400-A
Application Form for Permit or Plan Approval
List only one piece of equipment or process per form.
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
1. Facility Name (Business Name of Operator to Appear on the Permit):
3. Owner’s Business Name (If different from Business Name of Operator):
2. Valid AQMD Facility ID (Available On
Permit Or Invoice Issued By AQMD):
Section A - Operator Information
Section B - Equipment Location Address Section C - Permit Mailing Address
4. Equipment Location Is: Fixed Location Various Location
(For equipment operated at various locations, provide address of initial site.)
Street Address
, CA
City Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail:
5. Permit and Correspondence Information:
Check here if same as equipment location address
Address
,
City State Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail:
7a. New Equipment or Process Application: 7c. Equipment or Process with an Existing/Previous Application or Permit:
New Construction (Permit to Construct)
Equipment On-Site But Not Constructed or Operational
Equipment Operating Without A Permit *
Compliance Plan
Registration/Certification
Streamlined Standard Permit
Administrative Change
Alteration/Modification
Alteration/Modification without Prior Approval *
Change of Condition
Change of Condition without Prior Approval *
Change of Location
Change of Location without Prior Approval *
Equipment Operating with an Expired/Inactive Permit *
* A Higher Permit Processing Fee and additional Annual Operating Fees (up to 3 full years) may apply (Rule 301(c)(1)(D)(i)).
7b. Facility Permits:
Title V Application or Amendment (Refer to Title V Matrix)
RECLAIM Facility Permit Amendment
8a. Estimated Start Date of Construction (mm/dd/yyyy):
8b. Estimated End Date of Construction (mm/dd/yyyy):
8c. Estimated Start Date of Operation (mm/dd/yyyy):
9. Description of Equipment or Reason for Compliance Plan (list applicable rule):
10. For Identical equipment, how many additional
applications are being submitted with this application?
(Form 400-A required for each equipment / process)
11. Are you a Small Business as per AQMD’s Rule 102 definition?
(10 employees or less and total gross receipts are
$500,000 or less OR
a not-for-profit training center)
12. Has a Notice of Violation (NOV) or a Notice to
Comply (NC) been issued for this equipment?
If Yes, provide NOV/NC#:
Section D - Application Type
6. The Facility Is: Not In RECLAIM or Title V In RECLAIM In Title V In RECLAIM & Title V Programs
7. Reason for Submitting Application (Select only ONE):
13. What type of business is being conducted at this equipment location?
14. What is your business primary NAICS Code?
(North American Industrial Classification System)
15. Are there other facilities in the SCAQMD
jurisdiction operated by the same operator?
16. Are there any schools (K-12) within
1000 feet of the facility property line?
Section E - Facility Business Information
No Yes No Yes
No Yes
No Yes
No Yes
No
Yes
Section F - Authorization/Signature I hereby certify that all information contained herein and information submitted with this application are true and correct.
17. Signature of Responsible Official:
18. Title of Responsible Official: 19. I wish to review the permit prior to issuance.
(This may cause a delay in the
application process.)
20. Print Name:
21. Date: 22. Do you claim confidentiality of
data? (If Yes, see instructions.)
23. Check List: Authorized Signature/Date Form 400-CEQA Supplemental Form(s) (ie., Form 400-E-xx) Fees Enclosed
Existing or Previous
Permit/Application
If you checked any of the items in
7c., you MUST provide an existing
Permit or Application Number:
