South Coast Air Quality Management District, Form 400-E-23 (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-23
Supplemental Permit Application for
Existing Agricultural Orchard Heaters
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 1
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 - Orchard Heater Equipment Description
Describe each orchard heater used as per the example below.
Note: Fuel: The type of fuel being combusted in the engine. Examples: Diesel, Natural Gas (NG), Liquefied
Petroleum Gas (LPG).
Annual Usage: The typical number of hours in a calendar year that the equipment operated or the number of
gallons of fuel consumed in a year. This information can be obtained from a non-resettable hour meter or from
annual fuel bills.
Make Model Serial Number
Heater Rating
(MMBtu/hour)
Fuel Type
Annual Usage
(hr/yr or gal/yr)
Example: Lazy Flame LF103X LFX237-9001 500,000 LPG 275 gal/yr
Use additional sheets as needed.
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.
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:
