South Coast Air Quality Management District, Form 500-E (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-E
Title V Exclusion/Exemption Request
Page 1 of 2
I certify that I am the responsible official for this facility as defined in AQMD Rule 3000 (b) (26). I also certify under penalty of law that I personally
examined, and am familiar with, the statements and information submitted in this document and all of its attachments. Based on my inquiry of those
individuals with primary responsibility for obtaining the information, I certify that the statements and information are to the best of my knowledge and
belief true, accurate, and complete. I am aware that there are significant penalties for submitting false statements and information or omitting required
statement and information, including the possibility of fine or imprisonment. (Check the appropriate box.)
a. I hereby request to be exempted from the Title V program because my facility's potential to emit is below the limits in Rule 3001 (b). Attached is
supporting documentation demonstrating my facility’s potential to emit including Form 400-A and applicable fees.
b. I hereby request to be exempted from the Title V program by accepting a permit condition that limits my facility's potential to emit below the emission
limits in Rule 3001 (b). Attached are Form 400-A, additional applications and all applicable fees to limit my facility’s potential to emit.
c. I hereby request a provisional exemption from the Title V program because of errors in reported emissions. Attached are supporting documentation,
throughput records, MSDSs, a complete copy of my facility’s revised Annual Emission Report (AER), Form 400-A, and applicable fees. The revised AER
shows that my actual emissions are below the thresholds specified in Rule 3008 (d). (Must complete Section VI of this form.)
d. I hereby request a provisional exemption from the Title V program because my most current Annual Emission Report (AER) shows that my actual
emissions are below the thresholds specified in Rule 3008 (d). No changes or corrections were made to the attached AER.
1. Facility Name (Business Name of Operator That Appears On Permit): 2. Valid AQMD Facility ID (Available On Permit Or Invoice
Issued By AQMD):
2. Permit and Correspondence Information:
Check here if same as equipment location address
Street Address
,
City State Zip
Contact Name
Contact Title
Phone # Ext. Fax #
E-Mail
Section I - Operator Information
Section III - Permit Mailing Address
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 understand that filing this request does not relieve me of my obligation to prepare and submit and application for a Title V permit unless I am
otherwise notified in writing that my exemption has been approved by AQMD.
Section V - Authorization/Signature
1. Equipment Location Address (For equipment operated at various locations
in AQMD’s jurisdiction, provide address of initial site):
Street Address
CA,
City State Zip
Contact Name
Contact Title
Phone # Ext. Fax #
E-Mail
Section IV - Certification Statement
Section II - Equipment Location
