South Coast Air Quality Management District, Form 500-A2 (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 500-A2
Title V Application Certification
Page 1 of 2
Read each statement carefully and check each that applies – You must check 3a or 3b.
1. For Initial, Permit Renewal, and Administrative Application Certifications:
a. The facility, including equipment that are exempt from written permit per Rule 219, is currently operating and will continue to operate in
compliance with all applicable requirement(s) identified in Section II and Section III of Form 500-C1,
i. except
for those requirements that do not specifically pertain to such devices or equipment and that have been identified as
“Remove” on Section III of Form 500-C1.
ii. except
for those devices or equipment that have been identified on the completed and attached Form 500-C2 that will not be
operating in compliance with the specified applicable requirement(s).
b. The facility, including equipment that are exempt from written permit per Rule 219, will meet in a timely manner, all applicable
requirements with future effective dates.
2. For Permit Revision Application Certifications:
a. The equipment or devices to which this permit revision applies, will in a timely manner comply with all applicable requirements
identified in Section II and Section III of Form 500-C1.
3. For MACT Hammer Certifications:
a. The facility is subject to Section 112(j) of the Clean Air Act (Subpart B of 40 CFR part 63), also known as the MACT “hammer.” The
following information is submitted with a Title V application to comply with the Part 1 requirements of Section 112(j).
b. The facility is not subject to Section 112(j) of the Clean Air Act (Subpart B of 40 CFR part 63).
1. Facility Name (Business Name of Operator That Appears On Permit): 2. Valid AQMD Facility ID (Available On Permit Or Invoice
Issued By AQMD):
3. This Certification is
submitted with a
(Check one):
4. Is Form 500-C2 included with this Certification? Yes No
a. Title V Application (Initial, Revision or Renewal)
b. Supplement/Correction to a Title V Application
c. MACT Part 1
Acid Rain Facilities Only: Please Complete Section IV
Section I - Operator Information
Section II - Responsible Official Certification Statement
1. Signature of Responsible Official:
2. Title of Responsible Official:
3. Print Name:
4. Date:
5. Phone #:
6. Fax #:
7. Address of Responsible Official:
Street # City State Zip
I certify under penalty of law that I am the responsible official for this facility as defined in AQMD Regulation XXX and that based on information and belief formed after
reasonable inquiry, the statement and information in this document and in all attached application forms and other materials are true, accurate, and complete.
Section III - Authorization/Signature
