Permit Serv
ices Division
Bay Area Air Quality Management District
375 Beale Street, Suite 600, Sa
n Francisco, CA 94105 • 415-749-4990
Major Facility Review
Certification Statement
FACILITY NAME ____________________________________________ FACILITY # _____________
STATEMENT OF COMPLIANCE:
I certify the following:
Read each statement carefully and initial each box for confirmation.
Based on information and belief formed after reasonable inquiry, the source(s) identified in the
Applicable Requirements and Compliance Summary form that is(are) in compliance will continue to
comply with the applicable requirement(s);
Based on information and belief formed after reasonable inquiry, the source(s) identified in the
Applicable Requirements and Compliance Summary form will comply with future-effective applicable
requirement(s), on a timely basis;
Based on information and belief formed after reasonable inquiry, information on application forms,
all accompanying reports, and other required certifications is true, accurate, and complete;
All fees required by Regulation 3, including Schedule P have been paid.
STATEMENT OF NON-COMPLIANCE
Read statement carefully. Initial box for confirmation if statement is true.
I certify the following:
Based on information and belief formed after reasonable inquiry, the source(s) identified in the
Schedule of Compliance application form that is(are) not in compliance with the applicable
requirement(s) will comply in accordance with the attached compliance plan schedule.
____________________________________________ ______________________________
Signature of Responsible Official Date
____________________________________________ H:\pub_data\TitleV\dataform\mfrform\T5-form\cert.doc
Name of Responsible Official
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signature
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