Fillable Form 400-CEQA: Secon A Facility Informaon California Environmental (SCAQMD)

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Form 400-CEQA: Secon A Facility Informaon California Environmental (SCAQMD)

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South Coast Air Quality Management District, Form 400-CEQA (2017.12)
South Coast Air Quality Management District
Form 400-CEQA
California Environmental Quality Act (CEQA) Applicability
1
A “project” means the whole of an acon which has a potenal for resulng in physical change to the environment, including construcon acvies, clearing or grading of land,
improvements to exisng structures, and acvies or equipment involving the issuance of a permit. For example, a project might include installaon of a new, or modicaon of an
exisng internal combuson engine, dry cleaning facility, boiler, gas turbine, spray coang booth, solvent cleaning tank, etc
2
Form 400-CEQA, Table 2 – Other Air Toxics and Their Screening Levels, contains a list of air toxics that either do not have a cancer potency (CP) or reference exposure level (REL)
approved by the Oce of Environmental Health Hazards Assessment (OEHHA) or have a combinaon of OEHHA-approved and non-approved CPs or RELs.
Page 1 of 2
Mail To:
SCAQMD
P.O. Box 4944
Diamond Bar, CA 91765-0944
Tel: (909) 396-3385
www.aqmd.gov
Secon A – Facility Informaon
1. Facility Name (Business Name of Operator to Appear on the Permit): 2. SCAQMD Facility ID:
3. Project Descripon:
Secon B – Review For Exempon From Further CEQA Acon
Check “Yes” or “No” as applicable. If “Yes” is checked for any question in Section B, skip Section C and proceed to page 2 and
complete Section D - Signatures.
Yes No
Is this applicaon for:
1.
A request for a change of operator only (without equipment or process change modicaons)?
2.
A funconally idencal permit unit replacement with no increase in equipment unit rang or emissions?
3.
A change of daily VOC permit limit to a monthly VOC permit limit?
4.
Equipment damaged as a result of a disaster during state of emergency?
5.
A Title V (e.g., SCAQMD Regulaon XXX) permit renewal without equipment or process change modicaons?
6.
A Title V administrave permit revision?
7.
The conversion of an exisng permit into an inial Title V permit?
Secon C – Review of Impacts Which May Trigger Further CEQA Review
Check “Yes” or “No” as applicable. To avoid delays in processing your application(s), explain all “Yes” responses on a separate
sheet and attach it to this form.
Yes No
1.
Is this project specically evaluated in a previously cered or adopted CEQA document?
If “Yes” is checked, aach a copy of the signed Noce of Determinaon to this form.
2.
Is this project specically exempted from CEQA by another enty (e.g., city or agency)?
If “Yes” is checked, aach a copy of the signed Noce of Exempon or other documentaon from the enty to this form.
3.
Is this project part of a larger project?
If “Yes” is checked, aach a separate sheet to briey describe the larger project.
4.
Will the project increase the QUANTITY of hazardous materials stored aboveground onsite or transported by mobile
vehicle to or from the site by greater than or equal to the amounts associated with each compound listed on Form 400-
CEQA, Table 1 - Regulated Substances List and Threshold Quanes for Accidental Release Prevenon
[hp://
www.aqmd.gov/home/regulaons/ceqa/ceqa-permit-forms]? If “Yes” is checked, aach a separate sheet to idenfy each hazardous
material and corresponding quanty to be transported, stored, or used.
5.
Will the project emit any air toxic listed on Form 400-CEQA, Table 2 - Other Air Toxics and Their Screening Levels [hp://
www.aqmd.gov/home/regulaons/ceqa/ceqa-permit-forms]
2
? If “Yes” is checked, aach a separate sheet to idenfy each air toxic and
corresponding quanty to be emied.
6.
Will the project require any demolion, excavaon, and/or grading construcon acvies that encompass an area
exceeding 20,000 square feet?
The SCAQMD is required by state law, the California Environmental Quality Act (CEQA), to review discreonary permit project applicaons for potenal air quality
and other environmental impacts. This form is a screening tool to assist the SCAQMD in clarifying whether or not the project
1
has the potenal to generate
signicant adverse environmental impacts that might require preparaon of a CEQA document [CEQA Guidelines § 15060(a)]. Form 400-CEQA and the instrucons
for guidance on compleng this form are available at hp://www.aqmd.gov/home/regulaons/ceqa/ceqa-permit-forms or
hp://www.aqmd.gov/home/permits/
permit-applicaon-forms. For each Form 400-A applicaon, also complete and submit one Form 400-CEQA. If subming mulple Form 400-A applicaons for the
same project at the same me, only one Form 400-CEQA is necessary for the enre project. If you need assistance compleng this form, contact Permit Services at
(909) 396-3385.
South Coast Air Quality Management District, Form 400-CEQA (2017.12)
Page 2 of 2
Secon C – Review of Impacts Which May Trigger Further CEQA (concluded)
Yes No
7.
Will the project ulize a boiler, engine, or other combuson equipment that uses fuel (e.g., gasoline, diesel, natural gas,
liqueed petroleum gas (LPG), or landll gas)?
If “Yes” is checked, then the applicant will need to calculate the amount of GHGs from
fuel use via on the Greenhouse Gas (GHG) online esmator [hp://www.aqmd.gov/home/regulaons/ceqa/ceqa-permit-forms
], and
aaching the printout or by conducng hand calculaons and providing the documentaon. Refer to the Instrucons for Form 400-CEQA for
guidance.
8.
Will the project ulize other types of equipment not addressed in Queson 7 that require the use of, or will generate, any
chemicals listed on Form 400-CEQA, Table 3 - Greenhouse Gases
[hp://www.aqmd.gov/home/regulaons/ceqa/ceqa-permit-
forms]? If “Yes” is checked, aach a separate sheet to idenfy each equipment unit, the chemical name(s), and the quanty of each
chemical idened.
9.
Will the project include the open outdoor storage of dry bulk solid materials that could generate dust?
If “Yes” is checked, include a plot plan with the applicaon package.
10.
Will the project result in or make worse noceable o-site odors from acvies that may not be subject to SCAQMD
permit requirements? For example, landlls, materials recovery/recycling facilies (MRF), and compost materials or other types of
greenwaste (e.g., lawn clippings, tree trimmings, etc.) have the potenal to generate odor complaints subject to SCAQMD Rule 402 –
Nuisance.
11.
Will the project cause an increase of emissions from marine vessels, trains and/or airplanes?
12.
Will the project increase demand for potable water at the facility by more than 262,820 gallons per day?
The following examples idenfy some, but not all, types of projects that may result in a “Yes” answer to this queson: 1) a project that
generates steam; 2) a project that uses water as part of operang air polluon control equipment; 3) a project that requires water as part of
the producon process; 4) a project that requires a new, or the expansion of an exisng, sewage treatment facility, new water lines, sewage
lines, sewage hook-ups etc.; 5) a project where the water demand exceeds the capacity of the local water purveyor to supply sucient water
for the project; 6) a project that requires new or the expansion of exisng, water supply and conveyance facilies; and, 7) a project that
requires water to hydrotest pipelines, storage tanks etc. for structural integrity.
13.
Will the project create an increase in the mass inow of euents to a public wastewater treatment facility that would
require a new, or revision to an exisng, Naonal Pollutant Discharge Eliminaon System (NPDES) or other related permit
at the facility?
14.
Will the project result in the need for more than 350 new employees?
15.
Will the project result in an increase in heavy-duty transport truck trac to and/or from the facility by more than 350
truck round-trips per day?
16.
Will the project result in an increase in customer trac by more than 700 visits per day?
17.
Will the project result in temporary or permanent noise or vibraon in excess of what is allowed by the applicable local
noise ordinance?
18.
Will the project create a permanent need for new or addional solid waste disposal?
Check “No” if the projected potenal amount of solid waste to be generated by the project is less than ve tons per day.
19.
Will the project create a permanent need for new or addional hazardous waste disposal?
Check “No” if the projected potenal amount of hazardous wastes to be generated by the project is less than 42 cubic yards per day (or
equivalent in pounds).
20.
Will the project include equipment that aer installaon or modicaon will change the visual character of the site and its
surroundings or block views?
21.
Will the project have equipment that will create a new source of external lighng that will be visible at the property line?
THIS CONCLUDES FORM 400-CEQA. INCLUDE THIS FORM AND ANY ATTACHMENTS WITH FORM 400-A.
Secon D – SIGNATURES
I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED HEREIN AND INFORMATION SUBMITTED WITH THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I
UNDERSTAND THAT THIS FORM IS A SCREENING TOOL AND THAT THE SCAQMD RESERVES THE RIGHT TO CONSIDER OTHER PERTINENT INFORMATION IN DETERMINING CEQA
APPLICABILITY.
1. Signature of Responsible Ocial of Firm:
2.
Title of Responsible Ocial of Firm:
3. Print Name of Responsible Ocial of Firm: 4. Date Signed:
5. Phone # of Responsible Ocial of Firm: 6. Fax # of Responsible Ocial of Firm: 7. Email of Responsible Ocial of Firm:
8. Signature of Preparer, (If prepared by person other than responsible ocial of rm): 9. Title of Preparer:
10. Print Name of Preparer: 11. Date Signed:
12. Phone # of Preparer: 13. Fax # of Preparer: 14. Email of Preparer:
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Form 400-CEQA: Secon A Facility Informaon California Environmental (SCAQMD)

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Completed 12 August 2020

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