South Coast Air Quality Management District, Form 400-E-21 (2014.07)
South Coast Air Quality Management District
Form 400-E-21
Supplemental Permit Application for Dairy Farms
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
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 - Operation Information (cont.)
Solid Manure Management /
Storage
Check here if this section does not apply
How is solid manure stored on your farm? Open Piles Covered (tarp) Piles Other
Is solid manure applied to your crop land? No Yes
If Yes, how often?
per year Estimated tons/year?
Is solid manure hauled off-site? No Yes
If Yes, how often?
per year Estimated tons/year?
Where is the manure hauled off to?
What other practices are used to handle solid manure (e.g. composting, etc.)?
If your farm composts manure then what type of composting is done?
None Windrow Aerated Static Pile (ASP) Enclosed ASP (e.g. Ag Bag, Gore, Cover, etc)
Other
On-Field Activities
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How many acres of cropland that you farm are contiguous to your dairy?
(Include crops separated by road & avenues.)
What method is used to apply manure to your land?
Flood Irrigation Sold Spreading Liquid Injection Sprinkler Irrigation Furrow Irrigation
Other
Other Equipment
Check here if this section does not apply
Note: If your farm has any of the following equipment, please fill out the appropriate form(s)
Grain Storage Silo (AQMD Form 400-E-16)
Stationary IC Engines (AQMD Form 400-E-13)
Gasoline Tanks (AQMD Form 400-E-11)
Other
Section E - 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:
