WASHOE COUNTY HEALTH DISTRICT
AIR QUALITY MANAGEMENT DIVISION
NOTICE OF EXEMPTION
FOR VALIDATION: A COPY of this form with a check or cash
FEES: Current fees, click here
Failure to complete and submit the NOE form within 14 calendar days of the close of escrow may result in enforcement
actions by the Washoe County Health District Air Quality Management Division.
Make checks payable to Washoe County Health District and mail to:
AIR QUALITY MANAGEMENT, 1001 E. Ninth Street, B171, Reno NV 89512 - (775) 784-7200
PROPERTY LOCATION
Property Address City State Zip
Parcel # (APN) Title Company or Mobile Home Dealer Escrow Number Closing Date
Buyer’s Email
New owner agrees to allow Health District access to property to perform
verification inspection for a period not to exceed 30 calendar days from escrow
The above signed hereby attest to the accuracy of the information contained in
this form. Failure to provide complete and accurate information may result in a
civil fine and penalty of up to $10,000.00 per day per DBOHRGAQM 020.040.
Print Name
Seller Signature Date
NOTARY:
State of
County of
This instrument was acknowledged before me
,
Notary Signature
on of , 20
NOTAR
Y SEAL
Print Name
Buyer Signature Date
NOTARY:
State of
County of
This instrument was acknowledged before me
,
Notary Signature
on of , 20
NO
TARY SEAL
PROPERTY CONTAINS (mark all that apply):
MANUFACTURED GAS UNIT or GAS RETROFIT NO WOOD- BURNING DEVICE
(Woodstove, pellet stove, fireplace, or hydronic heater)
FIREPLACE ONLY: UNCERTIFIED DEVICE REMOVED FROM PROPERTY
(Doors are not gasketed to make device airtight.) PRIOR TO SALE. (Not Previously Inspected)
For more information on Notic
e of Exemption Form or Wood-Burning
Devices, please visit OurCleanAir.com
AWS #
AIR QUALTIY
MANAGEMENT
USE ONLY
Rev: 06/30/21
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
