Revised 09 January 2020
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
AIR PERMIT CANCELLATION/CLOSEOUT REQUEST (NOT TO BE USED FOR DUST CONTROL PERMITS)
Form Submittal
Forms may be submitted by email. After completing the form electronically, save it to your computer, then attach and email the form to
AQPermits@maricopa.gov.
Forms may also be submitted in person or mailed to either of the following locations:
1. Maricopa County Air Quality Department, 3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
2. One Stop Shop, 501 N. 44th St., Suite 200, Phoenix, AZ 85008
Email will be the department's primary means for routine communication with you, unless you do not have an email account. Please be
sure that your e-mail address is entered correctly.
Facility ID: Requested By: Title:
Business Name:
Date:Contact Email:
Business Address: City: State:
Zip:
Owner Name:
Owner Address: City: State: Zip:
Reason for Cancellation/Closeout:
If yes, keep fees. How much?
Compliance - Closeout Inspected by (if necessary):
Title:
Email:
Phone:
Company:
Permittee Name:
Other:
New Owner:
New Permit Number:
I certify that the above mentioned business has ceased all air quality permit related operations and activities at the at the above referenced
location or all ownership rights have been transferred to a new owner.
Check and complete all that apply:
New Owner Name:
All permitted equipment removed/permanently disconnected from site.
Other:
Permittee Name: Phone Number:
Company Name:
Signature:
Title:
New Facility ID:
Permittee Email:
Office Use Only
Compliance: Closeout Inspected by (if necessary) Date:
Finance: Indicate any unpaid fees
Enforcement: Indicate any pending enforcement actions
Permitting: Indicate if this is approved for cancellation/closeout
Manager/Supervisor Signature:
click to sign
signature
click to edit
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click to sign
signature
click to edit
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