Fillable Form 500-N: Section I - Operator Information Title (SCAQMD)

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Form 500-N: Section I - Operator Information Title (SCAQMD)

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South Coast Air Quality Management District, Form 500-N (2014.07)
Mail To:
SCAQMD- Compliance & Enforcement
P.O. Box 4941
Diamond Bar, CA 91765-0941
Tel: (909) 396-3385
www.aqmd.gov
South Coast Air Quality Management District
Form 500-N
Title V - Deviations, Emergencies & Breakdowns
*This written report is in addition to requirements to verbally report certain types of incidents. Verbal reports may be made by
calling AQMD at 1-800-288-7664 (1-800-CUT-SMOG) or AQMD enforcement personnel.
AQMD
USE
ONLY
Received By: Assigned By: Inspector:
Date/Time Received: Date/Time Assigned: Date/Time Received Assignment:
Date Delivered To Team: Date Reviewed Inspector Report: Date Inspected Facility:
Team: Sector: Breakdown/Deviation Notification No. Date Completed Report:
Recommended Action: Cancel Notification Grant Relief Issue NOV No. Other:
Final Action: Cancel Notification Grant Relief Issue NOV No.
Other:
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. Address:
(where incident occurred) Street Address
City State Zip
4. Mailing Address:
(if different from Item 3) Street Address
City State Zip
5. Provide the name, title, and phone number of the person to contact for further information:
Name Title Phone #
Section I - Operator Information
1. This written notification is to report a(n):
2. The incident was first discovered by:
on AM
Name Date Time PM
3. The incident was first reported by:
on AM
Name of AQMD Staff Person Date Time PM
a. Via Phone
b. In Person Notification Number (Required):
4. When did the incident actually occur?
AM
Date Time PM
Section II - Reporting of Breakdowns, Deviations, and Emergencies
Type of Incident Verbal Report Due* Written Report Due
a. Emergency under Rule 3002(g)
Within 1 hour of discovery Within 2 working days from when the emission limit was
exceeded.
b. Breakdown under:
Rule 430 (Non-RECLAIM)
Rule 2004 (RECLAIM)
Rule 218 (Non-RECLAIM)
[See Rule 218(f)(3)]
For Rules 430 & 2004 - Within 1 hour of
discovery.
For Rule 218 – Within 24 hours or next business
day for failure/shutdown exceeding 24 hours
For Rules 430 & 2004 - Within 7 calendar days after
breakdown is corrected, but no later than 30 days from
start of the breakdown, unless a written extension is
granted.
For Rule 218 - With required semi-annual reports.
c. Deviation with excess emissions
[See Title V Permit, Section K, Condition No. 22B]
Within 72 hours of discovery of the deviation or
shorter reporting period if required by an
applicable State or Federal Regulation.
Within 14 days of discovery of the deviation.
d. Other Deviation
[See Title V Permit, Section K, Condition Nos. 22D & 23]
None With required semi-annual monitoring reports.
CA
South Coast Air Quality Management District, Form 500-N (2014.07)
5. Has the incident stopped? a. Yes, on:
AM b. No
Date Time PM
6. What was the total duration of the incident?
Days Hours
7. For equipment with an operating cycle, as defined in Rule 430 (b)(3)(A),
when was the end of the operating cycle during which the incident occurred?
AM
Date Time PM
8. Describe the incident and identify each piece of equipment (by permit, application, or device number) affected. Attach photos (when available) of the affected
equipment and attach additional pages as necessary.
9. The incident may have resulted in a:
a. Violation of Permit Condition(s):
b. Violation of AQMD Rule(s):
10. What was the probable cause of the incident? Attach additional pages as necessary.
11. Did the incident result in excess emissions? No Yes (Complete the following and attach calculations.)
VOC
lbs NOx lbs SOx lbs H2S lbs
CO
lbs PM lbs Other: lbs pollutant
12. For RECLAIM facilities Subject to Rule 2004 (i)(3) ONLY: If excess emissions of NOx and/or SOx were reported in Item 11, do you want these emissions to be counted
when determining compliance with your annual allocations?
a. Yes, for: NOx SOx b. No, for: NOx SOx
If box 12(b) above is checked, include all information specified in Rule 2004(i)(3)(B) and (C), as applicable.
13. Describe the steps taken to correct the problem (i.e., steps taken to mitigate excess emissions, equipment repairs, etc.) and the preventative measures employed to
avoid future incidents. Include photos of the failed equipment if available and attach additional pages as necessary.
14. Was the facility operating properly prior to the incident?
a. Yes b. No, because:
15. Did the incident result from operator error, neglect or improper operation or maintenance procedures?
a. Yes b. No, because:
16. Has the facility returned to compliance?
a. No, because:
b. Yes (Attach evidence such as emissions calculations, contemporaneous operating logs or other credible evidence.)
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 based on information and belief formed after reasonable inquiry, the statements and information in this document and in all attachments
and other materials are true, accurate, and complete.
For Title V Facilities ONLY: I also certify under penalty of law that that I am the responsible official for this facility as defined in AQMD Regulation XXX.
Section III - Certification Statement
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Form 500-N: Section I - Operator Information Title (SCAQMD)

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Completed 27 January 2021

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