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-AO
Application For Additional Operator
Submit one form for each application/permit.
South Coast Air Quality Management District, Form 400-AO (2014.07)
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
Section A - Current Operator 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):
Section B - Additional Operator Information
3. Business Name of Operator As It Should Appear On The Additional Operator’s Permit:
4. Owner’s Business Name (If different from Business Name of Operator):
Section C - Equipment Location Address Section D - Permit Mailing Address
5. 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
6. Permit and Correspondence Information:
Check here if same as equipment location address
Address
,
City State Zip
Contact Name Title
Phone # Ext. Fax #
E-Mail
Section E - Facility Business Information
7. What business is conducted at this location? 8. What is your primary NAICS Code (North American Industrial
Classification System)?
9. Are you a small business as per AQMD’s Rule 102 definition? No Yes
(10 employees or less and total gross receipts are $500,000 or less or a not-for-profit training center)
Section F - Application or Permit Information
10. Application Number: 11. Permit Number: (Please attach a copy)
Section G - Signature and Authorization for Additional Operator
I HEREBY AUTHORIZE THE ADDITIONAL OPERATOR TO OBTAIN A PERMIT FOR THE EQUIPMENT AS SPECIFIED ABOVE.
Checklist
Form signed?
Payment attached?
Copy of existing permit
attached?
Form 400-CEQA attached?
12. Check all that apply: I am the Primary Operator Owner
13. Signature:
14. Print Name:
15. Title:
16. Date:
17. Phone:
18. Signature of Additional Operator:
19. Print Name:
20. Title:
21. Date:
22. Phone:
New AQMD Facility ID
(TO BE COMPLETED BY AQMD)
