Revised 24Jan19
Maricopa County
Air Quality Department
Return completed form to:
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
Documents may be submitted in person at:
3800 N. Central Ave. Suite 1400, Phoenix, AZ 85012 or 501 N. 44th Street, Suite 200, Phoenix, AZ 85008.
DUST PERMIT CANCELLATION REQUEST
Date:
Permit Holder:
Permit Number: Project Name:
Project Address:
City: State: Zip:
Phone Number
Reason for cancellation:
I verify that the above mentioned company has ceased soil disturbing activities at the above referenced location. All project soils
designated in the Dust Control Permit have been permanently stabilized by the following method(s) or included in a new permit.
(Check all that apply):
Buildings, Landscaping and/or Paving
Application of gravel cover and/or dust palliative
<1/10 acre disturbed soil remains
Other method (describe)
New permit # is:
Certification by the permit holder: I certify that the information provided in this application and accompanying documents is true, correct
and complete to the best of my knowledge.
Signature: Title:
Email: Date:
Official Use Only:
Approved By: Date:
Important: Please note that email will be our primary means for routine communication with you, unless you do not have an
email account. Please be sure that your email address is entered correctly.
click to sign
signature
click to edit
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