South Coast Air Quality Management District, Form 400-E-19 (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-19
Particulate Matter Control
Asbestos And/Or Lead Removal Equipment
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
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.
a. Negative Air Machine (Fee Schedule A) c. Canister Type Vacuum (Fee Schedule A)
b. Hand-held Vacuum (operated outside a negative air enclosure)
Fee Schedule A) (AQMD ECC - 32)
d. Abatement System (includes breaking, vacuuming, filtering and
collection) (Fee Schedule B) (AQMD ECC - 3B)
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
Equipment Type
Equipment
Manufacturer: Model: Serial No.:
Exhaust Blower Capacity
CFM
Section C - Operation Information
Does the removal include lead? Yes No
Will this equipment be moved to various job sites?
Yes. A “Various Location” permit will be issued.
No. Please indicate equipment location:
As indicated on Form 400-A
Other location address:
Street / City / Zip
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:
