Instructions for Application Forms and Fee Schedule Page

Instructions for Your Permit Application Form

A Filing Fee Per Unit Must Accompany Every Application

See the Fee Schedule below for your Application Fee

PLEASE NOTE: No person shall knowingly make any false statement in any application for a permit, or in any information, analysis, plans or specifications submitted in conjunction with the application or at the request of the Air Pollution Control Officer (APCO). Any applicant who fails to submit any relevant facts or who has submitted incorrect information in the Permit Application Form shall, upon becoming aware of such failure or incorrect submittal, promptly submit such supplementary factors or corrected information to the APCO. The APCO may request additional information, as needed, to supplement the Permit Application Form.

If sufficient space is not available on the Permit Application Form, please attach additional information on a separate piece of paper.

1. OPERATION AND OWNERSHIP:

The purpose of this section is to provide required information to identify the organization/facility name, address, and appropriate project contact to be used for Authority-to-Construct or Permit-to-Operate applications. Please note that the information provided in this section of the form will appear exactly as indicated in the permit issued. In addition, please note that all permits and billing information will be sent to the first address listed in this section.

• Name: Fill in the legal name of the Business, Company, Individual Owner, or Governmental Agency.
• Facility: Fill in the name and location of the facility where the emissions unit will be located.
• Project: Identify the name and address of the contractor, consultant, or contact person if different from the person identified above for the organization.

1. REASON FOR APPLICATION SUBMITTAL:

Please check the one box that best describes the permit action pursued in this application form. If there is not an appropriate box, please check “Other” and include a brief description. As indicated on the application form, please provide any related permit number(s) and expiration dates for the project,  if known.

Please indicate if the proposed permit unit will be located within 1000 feet of the outer boundary of a school site. For additional information, see Health and Safety Code Sections 42301.6.

Please indicate if you are submitting data or information that is confidential or proprietary in nature (for example, trade secrets or data that yields a competitive advantage).

Please indicate if this permit action is a result of a district enforcement action; please provide the District’s enforcement citation number, if known.

1. GENERAL NATURE OR BUSINESS OR AGENCY:

Please provide a brief description of the general nature of the business or agency activity (e.g., auto body painting, gasoline storing & dispensing, grain elevator, sand & gravel operations, asphalt/concrete plant, oil production, oil refinery, etc).

1. PROCESS/PROJECT DESCRIPTION:

Please provide a brief description of the process proposed for construction or modification. Please attach additional sheets if necessary.

1. PROJECT STATUS: Please indicate the estimated starting date(s) and completion date(s) for the proposed project.

1. DISTRICT SPECIFIC QUESTIONS: This section is provided for explanations of district specific questions. Provide supplementary information required per the attached list(s).

1. SIGNATURE OF RESPONSIBLE OFFICIAL, PARTNER, OR SOLE PROPRIETOR: The original Permit Application Form shall be signed in this section by the responsible official, partner, or sole proprietor; the signature implies certification based on information and belief formed after reasonable inquiry, and the information in this Permit Application Form is true, accurate, and comple