Fillable Form 500-SAM: Title V - Semi-Annual Monitoring Report (SCAQMD)

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Form 500-SAM: Title V - Semi-Annual Monitoring Report (SCAQMD)

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South Coast Air Quality Management District, Form 500-SAM (2014.07)
South Coast Air Quality Management District
Form 500-SAM
Title V - Semi-Annual Monitoring Report
∗ For each deviation, emergency or breakdown that occurs, in most cases, your facility should have already verbally reported the incident. A notification number
is assigned when the incident is verbally reported or Form 500-N is submitted. You will need this number to avoid submitting a duplicate Form 500-N with this
report
Page
of
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. This report is based on the applicable rules, permit terms and requirements as specified in Sections A
through K and Appendices A and B inclusive, and any compliance plans, variances, and alternative
operating conditions in effect during the permit term of the Title V Facility Permit to Operate issued on:
(mo/day/year)
5. This report supersedes a semi-annual monitoring report previously submitted on:
(mo/day/year)
Section I - Operator Information
1. Indicate the status of Deviations, Emergencies & Breakdowns during this reporting period
∗
:
a. This facility has not experienced any deviations, emergencies or breakdowns.
b. This facility has experienced one or more deviations, emergenci
es or breakdowns as indicated in the table below
∗
:
Section II - Reference Summary of Deviations, Emergencies & Breakdowns Reported
Type of Incident
Indicate Deviation (D),
Breakdown (B), or
Emergency (E)
Notification
Number
Was Form 500-N previously submitted for the non-compliance?
(Attach additional sheets as necessary)
D B E
Yes, on:
(mo/day/year)
No, Form 500-N is attached to this report
D B E
Yes, on:
(mo/day/year)
No, Form 500-N is attached to this report
D B E
Yes,
on:
(mo/day/year)
No, Form 500-N is attached to this report
D B E
Yes,
on:
(mo/day/year)
No, Form 500-N is attached to this report
D B E
Yes,
on:
(mo/day/year)
No, Form 500-N is attached to this report
D B E
Yes, on:
(mo/day/year)
No, Form 500-N is attached to this report
4. This report
is due:
(mo/day/year)
and covers the
period from:
(mo/day/year)
to:
(mo/day/year)
Clear
C
C
C
C
C
C
South Coast Air Quality Management District, Form 500-SAM (2014.07)
Page 2 of 2
Mail Original to: SCAQMD- Compliance & Enforcement
P.O. Box 4941
Diamond Bar, CA 91765
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 I am the responsible official for this facility as defined in AQMD Regulation XXX and that based on information and
belief formed after reasonable inquiry, the statements and information in this document and in all attached application forms and other materials are
true, accurate, and complete.
Section IV - Responsible Official Signature Statement
1. Was all monitoring as required by the permit conducted?
a. Yes
b. No
If No, Please Explain:
Section III - Semi-Annual Monitoring Report
South Coast Air Quality Management District, Form 500-SAM (2014.07)
South Coast Air Quality Management District
Form 500-SAM
Title V - Semi-Annual Monitoring Report
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Form 500-SAM: Title V - Semi-Annual Monitoring Report (SCAQMD)

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Completed 27 January 2021

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