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Refundrequestform-pdf

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BAY AREA AIR QUALITY MANAGEMENT DISTRICT
REFUND REQUEST FORM
For requesting a refund for an overpayment
All fields are required unless otherwise noted. Please type or print.
Mail to:
BAAQMD
Permit Help Desk
375 Beale St.
, Suite 600
San Fr
ancisco, CA 94105
Attn: Refund Request
(415) 749-8665
Complete sections 1, 2, 3 and 4.
Refunds will not be processed until
o Business for that invoice has been completed; and
o All outstanding invoices have been settled.
1. General Information
Facility Name
BAAQMD Facility ID
Invoice #
Application # (if applicable, optional)
2. Who should BAAQMD contact for follow-up?
Name
Title
Mailing Address (Street, city, state, zip)
Email Address
Phone #
3. Reason for Request
Please provide a detailed explanation of the reason(s) why you are asking for the refund:
4. Signature of person responsible for the information on this form.
Name
Title
Signature
Date
BAAQMD Office Use Only – Skip this section
Open invoice(s)
Resolved
By
Date
To Finance
Page 1 of 1 An electronic version of this form and instructions can be found at www.baaqmd.gov. v06/2016
BAY AREA AIR QUALITY MANAGEMENT DISTRICT
BAAQMD
Engineering Division
375 Beale St.
, Suite 600
San Fr
ancisco, CA 94105
Instructions: Refund Request Form
Introduction Use the following instructions to help guide you through the Refund Request form.
Qualifications After business with BAAQMD has been completed, any payment amount above the
required fees may qualify for a refund. Fees are assessed (charged) according to
BAAQMD Regulation 3.
A refund cannot be processed until:
1. The business associated with the overpayment has been completed. Examples
include:
o For a permit renewal payment, your permit has been renewed or you
no longer need to renew your permit for the upcoming permit period.
Refund requests cannot be accepted once the new permit period has
started.
o For permit applications, the application process was completed: permit
document(s) issued, application withdrawn/canceled, application
denied.
2. All outstanding invoices have been settled
General
Information
BAAQMD Facility ID - The facility ID is available on your current permit document or
invoice issued by BAAQMD. It may be referred as a Plant or Site number.
Invoice # - Th
e invoice number is available on your invoice issued by BAAQMD.
Application # - If
the refund is a result of an overpayment on permit application,
identify the application number.
Who should
BAAQMD
con
tact for
follow-up?
Provide contact information in case the Air District has questions regarding this request.
Reason for
Request
To help understand your situation, provide a detailed reason for your request.
Still need help?
Call the Help Desk at (415) 749-8665.
Page 1 of 1 v06/2016
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Completed 21 April 2020

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