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
Page1of1 Anelectronicversionofthisformandinstructionscanbefoundatwww.baaqmd.gov. v05/2016
1. FacilityIdentification
FacilityName BAAQMDFacilityID
2. PermitConditionIdentificationAttachaseparatesheetforadditionalspace
Asidentifiedonthepermit,providethePermitConditionIDthatyouarerequestingthechange.
PermitConditionID
3. DescriptionoftheRequestedPermitConditionChangeAttachaseparatesheetforadditionalspace
Ihave:
(Selectone)
Attachedproposedlanguagetothisform Describedmyrequestinthespacebelow
Describethepermitconditionchangebeingrequested.IncludeBAAQMDdeviceIDs,ifnecessary.
4. Certification/Signatureofpersonresponsiblefortheinformationonthisform.
Thisformcontainsconfidentialinformation. No Yes (IfYes,seeinstructions.)
IherebycertifythatIamauthorizedtocompletethisformforthefacilityandthatallinformationcontainedhereinistrue
andcorrect.
Name Title
Signature Date Phone(xxxxxxxxxx)
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:PermitConditionChangeRequestForm
Introduction UsethefollowinginstructionstohelpguideyouthroughthePermitConditionChange
RequestForm.
Whoshoulduse
thisform?
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.
Whatadditional
formsare
needed?
APermitApplicationCoverform 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.,GasDispensingFacilityform)
General
Information
BAAQMDFacilityID 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.
Stillneedhelp? CalltheEngineeringDivisionat(415)749‐4990.