South Coast Air Quality Management District, Form 400-PS (2015.04)
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-PS
Plot Plan And Stack Information Form
This form must be accompanied by a completed Application for a Permit to Construct/Operate - Form 400A and Form 400-CEQA.
Page 1 of 2
Section A - Operator Information
Facility Name (Business Name of Operator To Appears On The 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
Plot Plan
Please attach a site map for the project with distances and scales. Identify and locate the proposed equipment on the map. A copy of the appropriate
Thomas Brothers page, a web-based map, or a sketch that shows the major streets and location of the equipment is acceptable.
Location of Schools Nearby
Is the facility located within a 1/4 mile radius (1,320 feet) of the outer boundary of a school? Yes No
If yes, please provide name(s) of school(s) below:
Population Density Urban Rural (<50% of land within 3 km radius accounted for by urban land use categories, i.e., multi-family dwelling or industrial.)
Section B - Location Data
Zoning Classification
Mixed Use Residential Commercial Zone (M-U) Service and Professional Zone (C-S) Medium Commercial (C-3)
Heavy Commercial (C-4) Commercial Manufacturing (C-M)
School Name:
School Address:
Distance from stack or equipment vent
to the outer boundary of the school:
feet
School Name:
School Address:
Distance from stack or equipment vent
to the outer boundary of the school:
feet
CA Health & Safety Code 42301.9: "School" means any public or private school used for purposes of the education of more than 12 children in
kindergarten or any of grades 1 to 12, inclusive, but does not include any private school in which education is primarily conducted in private homes.
Stack Data
Receptor Distance From
Equipment Stack or Roof
Vents/Openings
feet
Distan
ce to nearest residence or sensitive receptor*:
Distance to nearest business:
feet
Building Information
Are the emissions released from vents and/or openings from a building? Yes No
If yes, please provide:
Section C - Emission Release Parameters - Stacks, Vents
Stack Height: feet (above ground level) What is the height of the closest building nearest the stack? feet
Stack Inside Diameter:
inches Stack Flow: acfm Stack Temperature: °F
Rain Cap Present: Yes No Stack Orientation: Vertical Horizontal
If the stack height is less than 2.5 times the closest building height (H), please provide information on any building within 5xH distance from the stack
(attach additional sheet if necessary):
Building #/Name:
Building
Height:
feet (above ground level)
Building Width:
feet
Building Length:
feet
Building #/Name:
Building
Height:
feet (above ground level)
Building Width:
feet
Building Length:
feet
Building #/Name:
Building
Height:
feet (above ground level)
Building Width:
feet
Building Length:
feet
*AQMD Rule 1470 defines SENSITIVE RECEPTOR as meaning any residence including private homes, condominiums, apartments, and living quarters, schools as defined under paragraph (b)(57), preschools,
daycare centers and health facilities such as hospitals or retirement and nursing homes. A sensitive receptor includes long term care hospitals, hospices, prisons, and dormitories or similar live-in housing.
