South Coast Air Quality Management District, Form 500-G (2014.07)
Mail To:
SCAQMD Title V Administration
21865 Copley Drive
Diamond Bar, CA 91765-4178
Tel: (909) 396-3385
www.aqmd.gov
South Coast Air Quality Management District
Form 500-G
Title V - Hearing Request Form
Page 1 of 2
This form is used to request a public hearing for a proposed Title V permit. To obtain copies of the public notices for Title V permits, or for assistance in completing the form, please call
the Title V Hotline at (909) 396-3013. Hearing requests should be returned to: AQMD Title V Administration, 21865 Copley Drive, Diamond Bar, CA 91765-0830. In addition, a copy
of this request MUST also be mailed by first class mail, on or before the date the hearing request is filed with the AQMD, to the facilities contact person identified in the Public Notice.
IMPORTANT - THE DEADLINE FOR RETURNING THE FORM IS 15 CALENDAR DAYS FROM THE DATE OF THE PUBLIC NOTICE. ALL INFORMATION MUST BE COMPLETE
FOR THE HEARING REQUEST TO BE CONSIDERED BY THE AQMD. See AQMD Rule 3006(a)(1)(F).
Section I - Individual Requesting a Public Hearing
1. Name:
2. Date of Request:
(mo/day/yr)
3. Company Name:
4. Title:
(if applicable)
5. Mailing Address:
Street Address/PO Box
City State Zip
6. Daytime Telephone:
Fax:
7. Signature of Requester:
I hereby request that the AQMD hold a public hearing to address concerns with the Title V Permit referenced below. I have
already mailed, by first class mail, a copy of this request to the contact person at the facility listed in the public notice.
Signature of Requester
8. Use the information from the public notice to identify the facility for which a hearing is requested by completing the following:
Valid AQMD Facility ID:
Notice Publication Date:
(Available on Permit or Invoice Issued by AQMD) (mo/day/yr)
Facility Name:
(Business name of operator to appear on permit)
Facility Location:
Street Address
City State Zip
Section II (Optional) - Alternate Person to Receive Further Notices
1. If applicable, provide the name and address of another person to whom all further notices should be sent, in lieu of the requester.
Name of Alternate Person:
Company Name:
Title:
Mailing Address:
Street Address/PO Box
City State Zip
-Turn page over and complete Section III.-
Ext.
