Fill - Free fillable Permit Condition Change Request Form (Bay Area Air Quality Management District) PDF form

BAY AREA AIR QUALITY MANAGEMENT DISTRICT

PERMIT CONDITION CHANGE REQUEST FORM

To request a change of current permit conditions



All fields are required unless otherwise noted. Please type or print.

Mail to:

BAAQMD

Engineering Division

375 Beale St., Suite 600

San Francisco, CA 94105



 Tel:(415) 749-4990

Page1of1 Anelectronicversionofthisformandinstructionscanbefoundatwww.baaqmd.gov. v05/2016 

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1. FacilityIdentification

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FacilityName BAAQMDFacilityID

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2. PermitConditionIdentification–Attachaseparatesheetforadditionalspace

Asidentifiedonthepermit,providethePermitConditionIDthatyouarerequestingthechange.

PermitConditionID



3. DescriptionoftheRequestedPermitConditionChange–Attachaseparatesheetforadditionalspace

Ihave:

(Selectone)

 Attachedproposedlanguagetothisform Describedmyrequestinthespacebelow

Describethepermitconditionchangebeingrequested.IncludeBAAQMDdeviceIDs,ifnecessary.



4. Certification/Signatureofpersonresponsiblefortheinformationonthisform.

Thisformcontainsconfidentialinformation. No Yes (IfYes,seeinstructions.)



IherebycertifythatIamauthorizedtocompletethisformforthefacilityandthatallinformationcontainedhereinistrue

andcorrect.

Name Title



Signature Date Phone(xxx‐xxx‐xxxx)

 



BAY AREA AIR QUALITY MANAGEMENT DISTRICT

BAAQMD

Engineering Division

375 Beale St., Suite 600

San Francisco, CA 94105

Page1of1  v05/2016

Instructions:PermitConditionChangeRequestForm



Introduction UsethefollowinginstructionstohelpguideyouthroughthePermitConditionChange

RequestForm.



Whoshoulduse

thisform?

Thisformshouldbesubmittedforallrequestedchangestocurrentlyassignpermit

conditions.PermitconditionscanbefoundonAuthoritytoConstructandPermitto

Operatedocuments.



Whatadditional

formsare

needed?



APermitApplicationCoverform mustaccompanythisform.



Ifyouarealsoproposingtomakechangestothedevice(s),theapplicabledeviceforms

mustbesubmittedwiththisform(e.g.,GasDispensingFacilityform)



General

Information

BAAQMDFacilityID ‐ Ifyouareanexistingfacility,filloutthisfieldsothatBAAQMD

canassociateyourchangestoyourfacility.ThefacilityIDisavailableonyourpermitor

invoiceissuedbyBAAQMD.



Permit

Condition

Identification

EnterthepermitconditionIDnumber fortheconditionyouarerequestingthechange,

whichislocatedonyourcurrentapplicablepermit(e.g.,AuthoritytoConstructand

PermittoOperate).



Description of

the Requested

Permit Condition

Change

Provideeitherproposedlanguageordescribetherequest.Ifthelatter,yourdescription

shouldincludetheBAAQMDdeviceIDsforpermitconditionsthataffectmultiple

devices.DeviceIDsareavailableonyourcurrentpermit.



Stillneedhelp? CalltheEngineeringDivisionat(415)749‐4990.



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Permit Condition Change Request Form (Bay Area Air Quality Management District)

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