South Coast Air Quality Management District, Form 400-E-22 (2014.07)
South Coast Air Quality Management District
Form 400-E-22
Supplemental Permit Application for Laying Hen Ranches
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.
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.
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.)
Manure/Litter Management /
Storage
How many tons/year of manure is generated at your ranch?
tons/year
What is the average frequency of manure cleanout from the houses?
per year
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?
What method is used to apply manure to your land?
Flood / Furrow Irrigation Spreading Liquid Injection Other
Feed Management
Check here if this section does not apply
What is the maximum annual amount of poultry feed received at the ranch?
tons/year
How is poultry feed stored at the ranch?
Feed Tanks Transport Containers (sacks) 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
Laying Hen Electric Fans
What is the total horsepower (hp) rating of all chicken house electric fans at your ranch?
Treatment Lagoon / Storage
Pond
Number of Lagoons:
Number of Storage Ponds:
List dimensions for each: List dimensions for each:
1. L:
W: D: 1. L: W: D:
2. L:
W: D: 2. L: W: D:
3. L:
W: D: 3. L: W: D:
How many settling basins are on your farm?
How often is manure water applied to your land?
per year
What controls are associated with the lagoon?
None Aerobic / Mechanical Treatment Anaerobic Digester Solids Separation
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:
