South Coast Air Quality Management District Form 400-A Application Form for Permit or Plan Approval List only one piece of equipment or process per form. Mail To: SCAQMD P.O. Box 4944 Diamond Bar, CA 91765-0944 Tel: (909) 396-3385 www.aqmd.gov 2. Valid AQMD Facility ID (Available On Permit Or Invoice Issued By AQMD): Section A - Operator Information 1. Facility Name (Business Name of Operator to Appear on the Permit): 3. Owner's Business Name (If different from Business Name of Operator): Section B - Equipment Location Address 4. Equipment Location Is: Fixed Location Various Location (For equipment operated at various locations, provide address of initial site.) Street Address City Contact Name Phone # E-Mail: Ext. , CA Title Fax # Zip Section C - Permit Mailing Address 5. Permit and Correspondence Information: Check here if same as equipment location address Address City Contact Name Phone # E-Mail: Ext. , State Zip Title Fax # Section D - Application Type 6. The Facility Is: Not In RECLAIM or Title V In RECLAIM In Title V In RECLAIM & Title V Programs 7. Reason for Submitting Application (Select only ONE): 7a. New Equipment or Process Application: New Construction (Permit to Construct) Equipment On-Site But Not Constructed or Operational Equipment Operating Without A Permit * Compliance Plan Registration/Certification Streamlined Standard Permit 7b. Facility Permits: Title V Application or Amendment (Refer to Title V Matrix) RECLAIM Facility Permit Amendment 8a. Estimated Start Date of Construction (mm/dd/yyyy): 7c. Equipment or Process with an Existing/Previous Application or Permit: Administrative Change Alteration/Modification Alteration/Modification without Prior Approval * Change of Condition Change of Condition without Prior Approval * Change of Location Change of Location without Prior Approval * Equipment Operating with an Expired/Inactive Permit * * A Higher Permit Processing Fee and additional Annual Operating Fees (up to 3 full years) may apply (Rule 301(c)(1)(D)(i)). Existing or Previous Permit/Application If you checked any of the items in 7c., you MUST provide an existing Permit or Application Number: 8b. Estimated End Date of Construction (mm/dd/yyyy): 8c. Estimated Start Date of Operation (mm/dd/yyyy): 9. Description of Equipment or Reason for Compliance Plan (list applicable rule): 10. For Identical equipment, how many additional applications are being submitted with this application? (Form 400-A required for each equipment / process) 12. Has a Notice of Violation (NOV) or a Notice to Comply (NC) been issued for this equipment? If Yes, provide NOV/NC#: No Yes 11. Are you a Small Business as per AQMD's Rule 102 definition? (10 employees or less and total gross receipts are No $500,000 or less OR a not-for-profit training center) Yes Section E - Facility Business Information 13. What type of business is being conducted at this equipment location? 15. Are there other facilities in the SCAQMD jurisdiction operated by the same operator? 14. What is your business primary NAICS Code? (North American Industrial Classification System) Yes 16. Are there any schools (K-12) within 1000 feet of the facility property line? No Yes No Section F - Authorization/Signature 17. Signature of Responsible Official: 20. Print Name: 23. Check List: AQMD USE ONLY DATE I hereby certify that all information contained herein and information submitted with this application are true and correct. 18. Title of Responsible Official: 19. I wish to review the permit prior to issuance. (This may cause a delay in the application process.) 21. Date: 22. Do you claim confidentiality of No data? (If Yes, see instructions.) Form 400-CEQA AMOUNT RECEIVED $ EQUIPMENT CATEGORY CODE No Yes Yes Authorized Signature/Date CHECK # Supplemental Form(s) (ie., Form 400-E-xx) PAYMENT TRACKING # TEAM ENGINEER REASON/ACTION TAKEN Fees Enclosed VALIDATION APPLICATION TRACKING # APP REJ DATE APP CLASS BASIC REJ I III CONTROL South Coast Air Quality Management District, Form 400-A (2014.07) American LegalNet, Inc. www.FormsWorkFlow.com