PETITION FOR APPEAL BEFORE THE HEARING BOARD OF THE SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT __________________________________________________________________________________________ CASE NO:_________________ FACILITY ID:_______________ IN THE MATTER OF 1. FACILITY NAME: ADDRESS: [location of equipment/operation; specify business/corporate address, if different, under Item 4, below] CITY, STATE & ZIP CODE: ( ) Ext. Fax ( ) 2. PETITIONER if different from above: ADDRESS: CITY, STATE & ZIP CODE: ( ) Ext. Fax ( ) NOTE: If the Petitioner is not the owner, operator and/or permittee of the facility you must answer No. 11, on Page 5. IMPORTANT FILING INFORMATION Your petition must be filed within 30 days of the action specified in Health & Safety Code Sections 42302.1, 42501, 42302, or 40713, or District Rules 215 or 216, as applicable. You are responsible for reviewing these code sections to determine the details governing the deadline for filing your petition. In order to be accepted by the Clerk of the Board for filing, your Petition for Appeal must: (i) Include an original and eight copies. The original petition must be printed on one side; the copies may be double-sided; and (ii) Be accompanied by the required filing fee, pursuant to SCAQMD Rule 303, Table III. A copy of Rule 303 may be obtained from the Clerk of the Board or via the SCAQMD website at www.aqmd.gov/rules/rulesreg.html . Persons with disabilities may request this document in an alternative format by contacting the Clerk of the Board at 909-396-2500 or by e-mail at clerkofboard@aqmd.gov. If you require disability-related accommodations to facilitate participating in the hearing, contact the Clerk of the Board at least five (5) calendar days prior to the hearing. [ALL DOCUMENTS FILED WITH CLERK'S OFFICE BECOME PUBLIC RECORD] American LegalNet, Inc. www.FormsWorkFlow.com 3. Petitioner respectfully submits to the Hearing Board this petition appealing the: ISSUANCE of OR DENIAL of Permits(s) to Construct Permits(s) to Operate Permit Condition(s) 4. Emission Reduction Credits (ERC) ____________________________ Plan OTHER _________________________ CONTACT(S): Name, title, company, address, and phone number of persons to contact and authorized to receive notices regarding this Petition (no more than two authorized persons). Zip Zip ( Fax ) ) Ext. Fax ( ( E-mail ) ) Ext. ( E-mail 5. 6. Is this a Title V facility? Yes No Yes No Is this petition a supplement to an appeal pending before the Hearing Board? If yes, indicate Case No. _______________________ Briefly describe the equipment or operation which is the subject of this petition. 7. [YOU MAY ATTACH ADDITIONAL PAGES IF NECESSARY] PAGE 2 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 8. Date Permit/Plan/ERC was issued/approved: _____________ denied/disapproved: ________________ Attach a copy of the permit, approval/denial letter, or any other relevant documentation. For RECLAIM or Title V facilities, attach only the relevant sections of the Facility permit showing the equipment or process and conditions that are the subject of this appeal. Provide a detailed statement discussing how and why the action of the Executive Officer was not proper. 9. [YOU MAY ATTACH ADDITIONAL PAGES IF NECESSARY] PAGE 3 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 10. State in detail the specific relief you seek. [YOU MAY ATTACH ADDITIONAL PAGES IF NECESSARY] PAGE 4 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 11. If you are the facility owner, operator, and/or permittee, skip to No. 12. If you are not, (a) Explain what your relationship is to the facility or to the action being appealed: (b) Explain what actions you or your representative has taken to appear, submit written testimony, or otherwise participate in the action pertaining to the issuance of the permit that is the subject of this petition. (See California Health & Safety Code Section 42302.1): 12. The undersigned, under penalty of perjury, states that the above petition, including attachments, and the items therein set forth, are true and correct. Date: Signature: Print Name: Title: [YOU MAY ATTACH ADDITIONAL PAGES IF NECESSARY] PAGE 5 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com 13. If you wish to waive your right to have your hearing held within 30 days of the date when you file your petition, sign the waiver of time statement that follows: Waiver of Time (Health and Safety Code Section 42308) I hereby waive and give up my right to a hearing within 30 days of the request for said hearing in the above-entitled case pursuant to California Health and Safety Code Section 42308. Date: Signature: Print Name: Title: 14. SMALL BUSINESS and TABLE III SCHEDULE A FEES: To be eligible for reduced fees for small businesses, individuals, or entities meeting small business gross receipts criterion [see District Rule 303(h)], you must complete the following: Declaration Re Reduced Fee Eligibility 1. The petitioner is a) b) an individual, or an officer, partner or owner of the petitioner herein, or a duly authorized agent of the petitioner authorized to make the representations set forth herein. If you selected 1a, above, skip item 2. 2. The petitioner is a) a business that meets the following definition of Small Business as set forth in District Rule 102: SMALL BUSINESS means a business which is independently owned and operated and meets the following criteria, or if affiliated with another concern, the combined activities of both concerns shall meet these criteria: (a) the number of employees is 10 or less; AND (b) the total gross annual receipts are $500,000 or less or (iii) the facility is a not-for-profit training center. -ORb) an entity with total gross annual receipts of $500,000 or less. 3. Therefore, I believe the petitioner qualifies for reduced fees for purpose of filing and appearance fees, in accordance with Rule 303(h). I declare under penalty of perjury that the foregoing is true and correct. Executed on____________________, at ____________________________________, California Signature Print Name Position with Company (Petition for Appeal: Revised December 10, 2008) [YOU MAY ATTACH ADDITIONAL PAGES IF NECESSARY] PAGE 6 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com