South Coast Air Quality Management District, Form 500-MACT (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-MACT
MACT Part 1 Application
Sources Subject to Section 112(j) Provisions 40 CFR 63.50 through 63.56
Page 1 of 2
Section I - Source Identification
1. Source Name: 2. Source ID No.:
Section II - Equipment Location Section III - Permit Mailing Address
3. 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
4. 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 IV - Applicability Determination
5. Is your facility a major source of hazardous air pollutants (HAP)? If not, you need not complete the rest of this form.
A major source is any contiguous area under common control that emits or has the potential to emit considering controls, in the aggregate, at least
10 tons per year of any single HAP or 25 tons per year total HAP.
Yes
No
6. Do you own or operate an affected source in a source category for which EPA has not promulgated standards under 40 CFR 63? If so,
which one(s)? If not, you need not complete the rest of this form.
(See Table of Promulgated Regulations, Table of Proposed Regulations, and Table of Upcoming Regulations at www.epa.gov/ttn/atw/eparules.html to
determine if your standard has not been promulgated.)
Yes
No
7. Provide a brief description of the major source and its activities:
