Application Instructions for Permit Shield Request
South Coast Air Quality Management District, Form 500-D (2014.07)
Page 2 of 2
A Title V facility has the option to use this form to request that their Title V permit contain a permit shield. A Title V permit with a permit shield will
identify rules that do not apply, and state that compliance with all conditions on the permit will be considered as compliance with all regulatory
requirements in effect as of the date of the date of permit issuance. A requirement identified in the permit as non-applicable is not enforceable by
EPA, the AQMD, or citizens. However, if a requirement is erroneously omitted from the permit, a permit shield will not protect a facility from
enforcement action.
General Instructions:
1. Submit one 400-A, one 500-A1, and one 500-D form for each permit unit. Facility permit holders: All devices with the same
application number are in the same permit unit.
2. Permit processing fee: If you are applying for equipment with an existing permit, you must also submit for each 500-D application
the permit processing fee specified for a change of conditions in the Summary Permit Fee Rates table in Rule 301. There is no fee
if you are requesting a permit shield for new equipment for which you are also applying for a permit.
3. Please type or print the information in the appropriate blanks.
Section I- Facility/Application Information
1. Facility ID: Complete this section only if the facility has been issued an identification or ID number by AQMD. If not, leave these
boxes blank. An ID number will be assigned when the application is submitted.
2. Application Type: Check “Change of Conditions” if the permit shield is for existing, permitted equipment. Check “New Equipment”
if the permit shield is for new equipment for which you are also applying for a permit.
3. Existing Equipment Permits: For RECLAIM/Title V facilities, enter the device nu
mber(s) for the permit unit (see Sections D and H
of the facility permit.) All devices with the same application number are in the same permit unit. For TV only facilities, enter the
permit number found on the equipment’s permit to operate.
4. If applying for new equipment that does not yet have a permit, leave this part blank.
5. Multiple Applications for Permit Shield: If you are requesting permit shields for multiple pieces of similar equipment (as
described in Rule 301), the permit fee for each of the second, third, etc. applications is only 25% of the fee for the first application.
Section II- Permit Shield Information
1. Regulatory requirements for which a permit shield is sought: In the space provided, describe the regulatory requirement that
the facility is requesting a shield for, and cite the rule reference and date of the rule version (e.g., Rule 1130 (b)(5), 08/02/91).
2. Reason(s) for requesting a permit shield: Explain reason(s) for requesting a permit shield for each regulatory requirement.
3. Estimated time that the permit shield should last: Check the appropriate box to indicate the duration or length of time over
which the permit shield should last.
