South Coast Air Quality Management District
Form 500–RO
Notification For Delegation of Title V Responsible Official
Mail
Application To
:
SCAQMD- Compliance & Enforcement
P.O. Box 4941
Diamond Bar, CA 91765
Tel: (909) 396-3385
www.aqmd.gov
Section A: Operator
I
n
f
o
r
m
a
t
i
on
1.
Business
Name of Operator as
it
Appears on the Pe
r
m
i
t:
2.
Valid
AQMD
Facility
ID
(Available
on
Permit
or I
nvo
i
c
e
issued
by
A
QMD)
:
3.
Owner’s Business
Name (If
different
from
Business
Name of O
p
e
r
a
t
o
r
)
:
As the Designated Title V Responsible Official for the above company, I hereby designate and assign the duties of Title V Responsible Official to the
person or persons listed below. Each person listed below qualifies as a Title V Responsible Official in accordance with AQMD Rule 3000(b)(29)*.
This delegation includes a) written reports for the follow-up verbally reported of Emergency, Breakdown, and Excessive Emission Deviations (AQMD
Form 500-N; b) Compliance Plans and Quality Improvement Plans (AQMD Form 500-C2); c) the Title V Semi-Annual Monitoring Report (AQMD Form
500-SAM); d) the Title V Annual Compliance Certification (AQMD Form 500-ACC); and e) any and all permit application forms for this facility.
Section B: Delegated
Responsible
Official 1
I
n
f
o
r
m
a
t
i
on
Section C: Delegated
Responsible
Official 2
I
n
f
o
r
m
a
t
i
on
4.
Responsible
Official 1 Name (please print or
t
yp
e)
:
10.
Responsible
Official 2 Name (please print or
t
yp
e)
:
5.
Responsible
Official 1 S
i
gn
a
t
u
r
e
:
11.
Responsible
Official 2 S
i
gn
a
t
u
r
e
:
6.
Responsible
Official 1 T
i
t
l
e
:
12.
Responsible
Official 2 T
i
t
l
e
:
7. Date S
i
gn
e
d
:
8. Effective Da
t
e
:
13. Date S
i
gn
e
d
:
14. Effective Da
t
e
:
9. Designated
Responsible Official
1 Contact I
n
f
o
r
m
a
t
i
on
Street Address 15. Designated
Responsible Official
2 Contact I
n
f
o
r
m
a
t
i
on
Street Address
City State Zip Code City State Zip Code
Phone Number: Phone Number:
Fax Number: Fax Number:
E-Mail address: E-Mail address:
Section D - Signature and
Authorization
for Delegation of
Responsible
Of
f
i
c
i
a
l
I certify under penalty of law that I am the
responsible official
for this
facility
as defined in AQMD
Regulation
3000(b)(29) and that based on
information
and belief formed
a
ft
e
r
reasonable
inquiry,
the
statements
and
information
in this
document
and in all attached
application
forms and other
materials
are true, accurate, and
co
m
p
l
e
t
e.
16. Print Name of Current
Responsible Official:
20. Da
t
e
:
17.
Signature
of Current
Responsible O
ff
i
c
i
a
l
:
21. Street Address of Current
Responsible O
ff
i
c
i
a
l
:
18. Title of Current
Responsible O
ff
i
c
i
a
l
:
City State Zip Code
19. Phone #
:
23. Fax #
:
22. Email Address of Current
Responsible O
ff
i
c
i
a
l
:
* From AQMD Rule 3000 § (b)
Definitions
(29) RESPONSIBLE OFFICIAL
m
ea
ns
:
(A) fo
r a corporation: a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or a person who performs similar policy-
making functions for the corporation, or a duly authorized representative provided the representative is responsible for the overall operational control of the facility, and either:
(i) the Executive Officer has approved a petition from the original responsible official to delegate this authority; or,
(ii) the facility employs more than 250 persons o
r has a gross annual sales or expenditures exceeding $25 million in second quarter 1980 dollars.
(B) for a partnership or sole proprietorship: general partner or proprietor, respectively.
(C) for a municipality, State, federal, or other public agency: a principal executive officer or ranking elected official.
(D) for Phase II Acid Rain facilities that do not meet the criteria in subparagraphs (b)(29)(A) or (C) of this rule: the designated representative responsible pursuant to Title IV of
the federal Clean Air Act.
© South Coast Air Quality Management District, Form 500-RO (2014.07)
