South Coast Air Quality Management District, Form 400-XPP (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 - XPP
Express Permit Processing Request
Form 400-A, Form 400-CEQA and one or more 400-E-xx form(s) must accompany all submittals.
AQMD
USE ONLY
APPLICATION TRACKING # TYPE
B C
EQUIPMENT CATEGORY CODE: FEE SCHEDULE:
$
VALIDATION
ENG. A R
DATE
ENG. A R
DATE
CLASS
I III
ASSIGNMENT
Unit Engineer
CHECK/MONEY ORDER
#
TRACKING # AMOUNT
$
Section A - Operator Information
1. Facility Name (Business Name of Operator To Appear On The Permit): 2. Valid AQMD Facility ID (Available On Permit Or Invoice Issued By
AQMD):
Section B - Equipment Location Address Section C - Permit Mailing Address
3. 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
4. Permit and Correspondence Information:
Check here if same as equipment location address
Address
,
City State Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail
I understand that the Expedited Permit Processing fees must be submitted at the time of application submittal,
and that the application may be subject to additional fees per Rule 301. I understand that requests for Express
Permit Processing neither guarantees action by any specific date nor does it guarantee permit approval; that
Express Permit Processing is subject to availability of qualified staff; and that once Express Permit Processing
has commenced, the expedited fees will not be refunded. I hereby certify that all information contained herein
and information submitted with the application are true and correct.
5. Signature of Responsible Official:
6. Title of Responsible Official:
7. Print Name of Responsible Official:
8. Date:
9. Phone #:
10. Fax #:
Section D - Authorization/Signature
