Fillable Form 400-PS.: Non-Emergency Internal Combustion Engine (SCAQMD)

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Form 400-PS.: Non-Emergency Internal Combustion Engine (SCAQMD)

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South Coast Air Quality Management District, Form 400-E-13b (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-E-13b
Non-Emergency Internal Combustion Engine
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and
Form 400-PS.
Page 1 of 2
Section A - Operator Information
Facility Name (Business Name of Operator That Appears On Permit): Valid AQMD Facility ID (Available On Permit Or Invoice Issued By AQMD):
Address where the equipment will be operated (for equipment which will be moved to various location in AQMD’s jurisdiction, please list the initial location site):
Fixed Location Various Locations
Section B - Equipment Description
Internal Combustion Engine
Is the ICE an EPA Certified or Qualifying Non-Road Engine? No Yes
If yes, provide EPA Certificate No., and attach copy:
Manufacturer: Model: Serial No.:
Date of Manufacture:
(mm/dd/yyyy) Date of Installation: (mm/dd/yyyy)
Note: For an ICE manufactured after 7/18/94, please provide manufacturer’s specification and guarantee.
Manufacturer Maximum Rating:
BHP@ RPM
ICE Function
(Check all that apply)
Electrical Generator Fire Pump Compressor Co-Generation
Flood Control Pump Driver Other (specify):
Type
Stationary Portable
How Is This Type of Equipment Used? (Check All That Apply) Within Facility Off-Site Rental Non-Rental
Fuel
Natural Gas LPG Refinery Gas
* Digester Gas* Landfill Gas*
Diesel Oil No. 2 Other
* :
*If Digester Gas, Landfill Gas, Refinery Gas, and/or Other are checked, attach fuel analysis indicating higher heating value and sulfur content.
Cycle Type Two Cycle Four Cycle
Combustion Type Lean Burn Rich Burn
No. of Cylinders
Four Six Eight Ten Twelve Sixteen Other:
Aspiration Type
Turbocharged Turbocharged/Aftercooled Naturally Aspirated
Timing Retarded 4
˚ (relative to standard timing)
Air Pollution Control
(If Applicable)
Selective Catalytic Reduction (SCR)
* No Controls
Selective Non-Catalytic Reduction (SNCR)
* Air Fuel Ratio Controller
Non-selective Catalytic Reduction (NSCR) Other (specify):
* Separate application is required.
Manufacturer: Model:
If already permitted, indicate Permit No.:
Device No.:
Stand-By Fuel
Natural Gas LPG Refinery Gas
* Digester Gas* Landfill Gas*
Diesel Oil No. 2 Other
* :
*If Digester Gas, Landfill Gas, Refinery Gas, and/or Other are checked, attach fuel analysis indicating higher heating value and sulfur content.
South Coast Air Quality Management District, Form 400-E-13b (2014.07)
South Coast Air Quality Management District
Form 400-E-13b
Non-Emergency Internal Combustion Engine
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Forms 400-A, Form 400-CEQA, and Form 400-PS.
Page 2 of 2
CONFIDENTIAL INFORMATION
Under the California Public Records Act, all information in your permit application will be considered a matter of public record and may be disclosed to a third party. If you wish to keep
certain items as confidential, please complete the following steps:
(a) Make a copy of any page containing confidential information blanked out. Label this page “public copy.”
(b) Label the original page “confidential.” Circle all confidential items on the page.
(c) Prepare a written justification for the confidentiality of each confidential item. Append this to the confidential copy.
THIS IS A PUBLIC DOCUMENT
Pursuant to the California Public Records Act, your permit application and any supplemental documentation are public records and may be disclosed to a third party. If you wish to
claim certain limited information as exempt from disclosure because it qualifies as a trade secret, as defined in the District’s Guidelines for Implementing the California Public Records
Act, you must make such claim at the time of submittal
to the District.
Check here if you claim that this form or its attachments contain confidential trade secret information.
Pollutants
Maximum Emissions Before Control Maximum Emissions After Control
gm/Bhp-hr
PPM
(15% O
2
)
gm/Bhp-hr
PPM
(15% O
2
)
ROG
NOx
CO
PM
SOx
Emissions Reference (attach):
Manufacturer’s Guarantee
Catalytic Manufacturer’s Guarantee
Source Test Data
EPA Emission Factors
Other (specify):
Section C - Operation Information
Fuel Consumption
Maximum Rated Load:
gal./hr. OR cu.ft./hr
Average Load:
gal./hr. OR cu.ft./hr.
Operating Schedule
Normal:
hours/day days/week weeks/yr
Maximum:
hours/day days/week weeks/yr
Emissions Data
Section D - Authorization/Signature
I hereby certify that all information contained herein and information submitted with this application is true and correct.
Preparer
Info
Signature: Date:
Title: Company Name:
Name:
Phone #: Fax #:
Email:
Contact
Info
Name:
Title: Company Name:
Phone #: Fax #:
Email:
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Form 400-PS.: Non-Emergency Internal Combustion Engine (SCAQMD)

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Completed 12 August 2020

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