PETITION NOT VALID UNLESS ACCOMPANIED BY FILING FEE AND COMPLETED "FACTS TO SUPPORT FINDINGS" FORM (IF REQUIRED)
THE DISTRICT SMALL BUSINESS ASSISTANT IS AVAILABLE TO ASSIST SMALL BUSINESSES
IN COMPLETING THE PETITION FORMS AND DEVELOPING COMPLIANCE SCHEDULES
Rev. 1/09
SAN DIEGO COUNTY
AIR POLLUTION CONTROL DISTRICT HEARING BOARD
PETITION FOR HEARING BOARD ACTION
(Attach additional pages, if needed)
Petitioner:
Mailing Address:
E-Mail Address:
Telephone #: Fax #:
Name of person authorized to receive notices:
(Name of Individual)
Organization Name:
Mailing Address:
E-Mail Address:
Petition No:
Date Filed:
Fee Paid:
Receipt No:
Description of Business Activity:
Ownership Status: Sole Proprietor Partnership Corporation Government Other (explain):
Equipment Address:
Description of Affected Process and Equipment Involved:
Purpose of the Petition:
Emergency Variance—30 days maximum
90-Day Variance—90 days maximum
Interim & Regular Variance—Interim portion valid
through date of Hearing on Regular portion
Regular Variance—1 year maximum
(except as provided for in 42358(b))
Product Variance—1 year maximum
(except as provided for in 42372(b))
Request Appeal of permit denied, suspended or conditionally
granted
Request permit revocation or variance revocation
Request Hearing Board decision be reheard
Request variance modification
Other:
a) Rule(s) for which Variance requested:
b) Time period requested (include final compliance date):
c) The District application and permit numbers that relate to this matter (attach copy of permit):
d) Has this matter been the subject of previous variance requests? If so, please provide petition numbers:
e) Why are you not in compliance and/or why can you not comply now?
f) Provide amount of allowable emissions associated with equipment and amount of calculated excess emissions due to
non-compliance (provide calculation basis):
g) Is this operation a small business as defined by the United States Small Business Administration, and are annual emissions
of air contaminants from the entire source less than 10 tons?
h) Supporting documents may be attached (indicate name and number submitted):
I declare, under penalty of perjury under the laws of the State of California, that the information provided above is true and correct.
Date Signed: Authorized Signature:
