and fax to: 949-248-8499
or e-mail to
For help completing this form, please call Yorke Engineering at 949-248-8490
PermitWorks Information Request
and Service Agreement
Please note: Items in bold capitals are required for an expedited, Certified Permitting Professional application. Please pay particular attention to these items.
Gas Company Account Executive: / Phone:PART 1 - FORM 400A INFORMATION
Company Information:
Company Name:Address:
Tax ID (IRS or SSN):
Type of Organization (e.g., corporation, individual, limited partnership, general partnership, government, etc.):
Small business (<$500,000 gross and <10 employees?): yes or no ?
Woman/Minority Owned?:
Are all facilities under the same ownership in compliance with all Air Pollution Control Rules:
yes or no ?
Average Annual Gross Income for the Company:
No. of Employees in the Company:
Name, title, and phone number of person who will sign application forms:
Do you wish to request expedited processing from the AQMD? (Additional fee is required)
PermitWorks Information Request and Service Agreement
page 2
Facility Information:
Facility Name:Address:
Contact Person:Title:
Telephone Number:Fax Number:
Type of Business and Standard Industrial Code (SIC)
New facility: Yes or No ?
IS EQUIPMENT LOCATED WITHIN 1000 FT OF OUTER BOUNDARY OF A PUBLIC OR PRIVATE School (Kindergarten - 12th Grade)?
if yes, provide address and phone number:
Number of employees at facility?
SCAQMD Facility ID Number:
Is this facility IN reclaim? YES NO (if yes, ATTACH a COPY OF the PERMIT)
IS THIS FACILITY IN title v? YES NO (if yes, ATTACH a COPY OF the PERMIT)
is there any other permitted equipment at this facility?
(if yes, ATTACH A COPY OF the PERMITS)
Are you the owner of the equipment under this application? if not, provide legal name of owner:
Permit Application Information:
Application for: (check one)New construction? Modification? Change of Permittee?
Existing equipment without permit? Change of permit condition? Change of location?
Existing equipment with expired permit?
Are you submitting multiple applications for identical equipment? If so, how many?
Have you been issued a notice of violation (NOV)? If so, give NOV Number and Date:
Previous Permittee and permit number (if applicable):
Number of jobs created by the addition/modification of this equipment:
Estimated Cost of Basic Equipment (without control equipment):
Estimated Cost of Control Equipment:
Schedule:
Estimated Construction Start Date: Estimated Completion Date:
Change Date (if applicable): Estimated Initial Operation Date:
for existing equipment, date installed:
Has a california environmental quality act (CEQA) document (e.g., environmental impact report) been required by another government agency? If so, give document name and for what agency
Are any of these permits discretionary?
Should this information be considered confidential: yes or no ?
PermitWorks Information Request and Service Agreement
page 3
PART 2 - AIR QUALITY CALCULATIONS INFORMATION
Source Information:
Source Type: Boiler/Process Heater Oven Ceramic Kiln ICEngine - Lean Burn
Charbroiler ICEngine - Rich Burn
Stationary Gas Turbine Solution Tank
Size of Equipment (heat rating in million Btu/hr for boilers, turbines, or ovens, hp for engines):
Equipment Configuration:
Boilers, ovens, heaters, kilns, soln. tanks, afterburners: (circle) Standard or LowNOx Burner
IC Engines: (circle all applicable) Standard, Clean-burn, Turbocharged, Aftercooled, or Timing Retarded 4 degrees
Turbines: (circle) Standard or Low NOx Combustor
Control Technology (Selective Catalytic Reduction, Selective Non-Catalytic Reduction, Catalytic Oxidation, Non-Selective Catalytic Reduction (i.e., catalytic converter), Water (or steam) Injection, or Catalytic Converter):
Operating Scenarios:
Average % Load:
Hours per day equipment is operated:
Average - Maximum -
Days per year equipment is operated:
Average - Maximum -
Maximum Days per month equipment is operated:
Average Days per week equipment is operated:
Average weeks per year equipment is operated:
Process Description and Backround Information:
briefly describe the facility’s operations and purpose/use of this equipment:please attach a copy of the manufacturer’s specifications of the unit, including emissions and control data, or any source test data
PermitWorks Information Request and Service Agreement
page 4
Pollutant Emission Factors Data: Please provide emission factors from Manufacturer or Source Emission Test Data, if available. If none are available, conservative default values will be used. Please include the units used, for example: lb/MMBtu, lb/hr, g/bhp-hr.
Criteria Pollutants / Uncontrolled Emissions (include units) / Emissions With Control Equipment or Percent ReductionNOx
CO
Reactive Organic Gases (Non-methane hydrocarbons, NMHC)
Particulate Matter (PM10)
SOx
If available, please provide air toxics data, otherwise standard emission factors will be used.
Air Toxics / Uncontrolled Emissions (include units) / Emissions With Control Equipment or Percent ReductionAcetaldehyde
Benzene
Formaldehyde
Polycyclic Aromatic Hydrocarbons (PAHs)
Naphthalene
Acrolein
Toluene
Xylenes
Other Toxics
(if applicable)
Non-Combustion Related Pollutant Emissions Data: Please provide emission factors for non-combustion related emissions. For example, ROG emissions from a bakery oven or toxic emissions from a solution tank.
Criteria Pollutants / Uncontrolled Emissions (include units) / Emissions With Control Equipment or Percent ReductionAir Toxics / Uncontrolled Emissions (include units) / Emissions With Control Equipment or Percent Reduction
PermitWorks Information Request and Service Agreement
page 5
PART 3 - RULE 1401 MODELING INFORMATION
Maximum Individual Cancer Risk (MICR) Screening, and Chronic and Acute Health Risk Calculation Data:
Equipment ParametersStack height above the ground (ft):
Distance from equipment to nearest off-site worker receptor *:
Distance from equipment to nearest other (i.e., residence, school, hospital, day-care center) receptor*:
If other permitted equipment at this facility , please describe permit units and attach a copy of the permit(s).
PROVIDE A MAP (HAND DRAWN IS OK) SHOWING THE GENERAL LAYOUT OF THE FACILITY, THE LOCATION AND SIZE OF MAJOR STRUCTURES, THE LOCATION OF THE NEW OR MODIFIED EQUIPMENT, AND THE DIRECTION AND DISTANCES TO THE NEAREST OFFSITE RESIDENCE, WORKER, and K-12 SCHOOL.
PermitWorks Information Request and Service Agreement
page 6
PART 4 - SOURCE SPECIFIC INFORMATION FOR FORM 400-E
[Complete only the page applicable to your source type.]
Additional Source Information Needed for Internal Combustion Engines
Manufacturer:Serial Number:
Model Number:
Manufactur date: / Use:Fire PumpCompressor DriverPump DriverFlood Control
PortableElectrical Generator
Rental Other ______
Engine Description:
Number of cylinders:Number of Cycles (2 or 4):
Lean or rich burn?
Select one: Turbocharged Turbocharged/Aftercooled Naturally Aspirated
Timing retarded 4o (relative to standard timing)
Engine Size (Manufacturer’s Rating): ______BHP @ ______RPM
Fuel Information:
Type of fuel: natural gas
Maximum load fuel consumption rate (gal/hr or cu.ft./hr):
Air to Fuel ratio:
Energy recovery from exhaust: yes or no ? (If yes, explain)
Is engine connected to an emission control device? if yes, and permitted, provide aqmd permit # or device # of control device:
catalytic converter Description:Air/fuel ratio controller description
Manufacturer:manufacturer:
model Number:model number:
serial No. (if known):serial no. (if known):
please attach a copy of the manufacturer’s data and emission guarantee.
Stack or Vent Data:
Total height above ground (ft.):Height above building (ft.):
Diameter (or width and length, in inches):Exhaust Pressure (in. H2O):
Exhaust gas temperature (F):Exhaust gas flowrate (cfm):
Does this stack serve other equipment: yes or no ?
PermitWorks Information Request and Service Agreement
page 7
Additional Source Information Needed for Boilers
Boiler Description
Manufacturer:Use: steam ( ______psig),Model Number: hot water, or
Serial Number or other ID number: other hot liquid
Boiler Rating/Heat Input (BTU/Hr):
Burner Description:
Gas Burner Manufacturer:
Number of Burners:
Burner Model Number:
Maximum rating per burner (cu ft/hr or mmbtu/hr):
Gas Burner mode of control: Manual Automatic on-off
Automatic high-low Automatic full modulation
Back-up fuel?
Stack or Vent Data:
Does this stack serve any other equipment: yes or no ?
stack height above ground:
Exhaust stack inside diameter (inches):
Stack exit temperature:
type of controls:
Low NOx burner
Flue Gas Recirculation
Selective Catalytic Reduction (SCR)
CO Catalyst
Oxygen Trim
Thermal DeNOx (NSCR)
Other (specify) ______
PermitWorks Information Request and Service Agreement
page 8
Additional Source Information Needed for Turbines
Turbine Description:Manufacturer:
Model Number:
Serial Number or other ID number:
Manufacturer's minimum input rating (mmbtu/hr or kw):
Manufacturer's Max. output rating of the turbine (BTU/hr, or kw):
Maximum cubic feet per hour of natural gas consumed:
Specifications:
Cycle Type: Simple cycle Combined cycle STLG others
Use: Electrical generation Driving pump/compressor steam generator
Emergency peaking unit Exhaust heat recovery other ______
Equipped with exhaust heat recovery steam generator (hrsg)?: yes or no
(If yes, attach description of size, flow rate, steam output capacity, and temperature profile.)
Equipped with duct burners: yes or no ?
If yes, provide burner description, fuel usage, combustion air input, and location of burner(s). Show all heat transfer surface locations with the HRSG and temperature profile.
Is duct burner used as air pollution control equipment? Yes or No
If Yes and duct burner is permitted, list Permit Number(s) or Device Number(s) of control equipment:
Emissions Control Equipment:
Steam/water injection: yes or no ?
If yes, injection rate = ______lbs water/lbs fuel or mole water/mole fuel (circle units)
Ammonia (NH3) Injection? Yes or No?
If yes, Injection Rate: ______lbs NH3/lbs fuel or mole NH3/mole fuel (circle units)
Combustor type (select one): tubular can-annular annular
Selective Catalytic Reaction: yes or no ?
If yes, Reactor temp. = ______F; NH3/NOX Feed Ratio = ______
Stack or Vent Data:
Height above ground (ft):Height above building (ft):
Exhaust stack diameter or width and length (inches):
Exhaust gas temperature (F):
Exhaust gas flowrate (cfm):
Total flowrate (cfm):
Does this stack serve any other equipment: yes or no ?
PermitWorks Information Request and Service Agreement
page 9
Additional Source Information Needed for Ovens
Oven Description:Manufacturer:Model Number:
Serial Number:
Specifications:
Oven dimensions: ______width; ______length; ______height
Rate of natural gas consumption: ______(cfm)
Max. Heat Input Rating (Based on Higher Heating Value): MM BTU/hr or KW
Burner Manufacturer, Model No.:
Number of Burners: Max. Rating Per Burner MM BTU per hour or KW (circle unit)
Standby fuel:
type of controls:
Low NOx burner Flue Gas Recirculation Selective Catalytic Reduction (SCR) CO Catalyst
Oxygen TrimThermal DeNOx (NSCR) Other (specify) ______
Fan data: Make Model Size CFM Hp
Exhaust fan______
Circulating fan______
Combustion blower______
Other______
Operational Data:
Oven Type:
BakeryCuringFluidized BedSolder Reflow
BakingDrying StrippingRoasting (specify):______
Method of Heating: Direct Fired Indirect Fired (specify):
Bakery Ovens: Yeast Percentage: _____%; Fermentation Time:______hours
Articles Processed:
Operating Temperature: Normal ______Maximum ______
Operation: Continuous BatchMin./Batch = ______
Method of Heating: Direct fired Indirect fired
Average time between coating and baking operations:
Description of coatings applied to articles prior to drying in oven:
Provide names of coatings and daily usage (gallons/day) of each coating used to coat articles prior to drying. Include type and amount of thinner added (gallons/day). (Attach MSDSs)
______
______
______
PermitWorks Information Request and Service Agreement
page 10
Additional Source Information Needed for Charbroilers (Food Broilers)
Broiler DescriptionEquipment Type (check one only):
Under-fired or food charbroiler Deep fat fryer
(Note: Equipment used in eating establishments does not require permit. However, there are filing requirements with the AQMD that must be fulfilled.)
Conveyorized or chain-driven Charbroiler Other (specify):_____
Manufacturer:
Model Number:
Serial Number or other ID number:
Size: Width ______(ft)Length ______(ft) Height ______(ft)
Shape:Back-up fuel?
Specifications:
Number of Burners:
Maximum rating per burner (Btu/hr):
Product(check all that apply):
Hamburger Chicken Beef steak Fish noodles
potato chips tortilla chips Other ______
Total lbs of meat, fish or chicken cooked/day: Max. ______Avg. ______
Cooking time: ______(min.) or Grate speed ______(ft/min)
Food conveyor: No. of motors ______Motor size ______(Hp)
Exhaust blower: No. of blowers______Motor size ______(Hp)
Stack or Vent Data:
Height above the ground: ______(ft) Height above building ______(ft)
Does this stack serve any other equipment: yes or no ?
Exhaust stack inside diameter or width and length (inches):
Stack exit temperature: ______oF
Exhaust flow rate: ______(cfm)
Total flow rate: ______(cfm)
Emission Control Equipment:
If emission control equipment is installed, attach type, model, serial number, manufacturer’s catalog. if already permitted, provide permit number or device number.
PermitWorks Information Request and Service Agreement
page 11
Additional Source Information Needed for Solution Tanks
Tank InformationReference Name or Number: ______
If part of process line, indicate process: ______
Size: Depth ______(ft, in)Width ______(ft, in) Length ______(ft, in)
Type of Solution Used:
Volume or Weight Percent analysis
Chemicals:______
Concentrations:______
(Attach Material Safety Data Sheets (msds))
Application of Solution:
AnodizingChemical Milling
Dip Coating
BatchWeb
ConveyorizedOther (specify):
Etching Passivation
Plating
Cadmium LeadNickel
Chrome, Specify type:Other (specify):
Stripping, Specify type:
Other (specify):
Rectifier Manufacturer:
Power:Maximum: ______Volts x ______Amps = ______(kW or KVA)
Average: ______Volts x ______Amps = ______(kW or KVA)
Operating Schedule:Av._____ Hr/Day Max._____ Hr/Day_____ Days/Wk_____ Wks/Yr
Heater:
Operating Temperature ______(F) Gas ______(Btu/hr) other ______
Agitation Method:
None Mechanical Solution Sparging
Air Sparging ______(CFM) Other ______
Venting:
None To Air ______(CFM/ft2)
To Scrubber ______(CFM/ft2) Scrubber Permit Number ______
Antimist or Mist Inhibiting Methods:
Plastic BeadsDiameter ______(in.) Layer Thickness ______(in.)
Mist Suppressant:Chemical Name: ______
Other ______
PermitWorks Information Request and Service Agreement
Additional Terms and Conditions
Limitation of Warranty and Disclaimer
Subject to the limitations herein, The Gas Company warrants that the calculations performed by the PermitWorks software are correct arithmetic computations with respect to the customer information provided. The Gas Company disclaims all other warranties, either express or implied, including but not limited to warranties of merchantability or fitness for a particular purpose.
The information required by the application, including but not limited to customer's emissions data and information relating to the customer's facilities and equipment, must be submitted by the customer for input. The customer is solely responsible for insuring that such information is complete and accurate. The Gas Company cannot independently verify the accuracy of this information and therefore, The Gas Company does not warrant, guarantee or make any representation that the completed application is correct, accurate, complete, reliable or otherwise. If The Gas Company assists the customer in obtaining emissions or other information from the manufacturers of customer's equipment, this does not constitute verification of customer information and the customer remains responsible for the accuracy of the equipment information.
The customer is solely responsible for insuring that all regulations that customer certifies compliance with for purposes of the application constitute all the regulations applicable to customer's facilities. Customer is solely responsible for the accuracy of the customer certifications. The Gas Company makes no warranty nor assumes any liability in regards to the applicability of the certified regulations or any other regulations which may apply to customer's facilities.
Payment Terms
Customer agrees to pay the basic charge and any other fees as set forth in the attached fee schedule. Payment is due and payable within 30 days of receipt of invoice.
Confidentiality
The Gas Company will treat customer information as private and confidential and will take reasonable measures to prevent unauthorized disclosure of such information outside of The Gas Company.
By:______By:______
Name:______Name:______
Title:______Title:______
Date:______Date:______
PermitWorks Fee Schedule
Check applicable schedule.
_____ Schedule A: Single Permit Application:
Fee Component / FeeBasic PermitWorks Fee / $600
Engineering Fee for permitting assistance over 4 hours per application / $125/hr
_____ Schedule B: Multiple Permit Applications at Same Site:
Fee Component / Fee1A. First Permit Application at Site:
Basic PermitWorks Fee / $600
Engineering Fee for permitting assistance over 4 hours for first application / $125/hr
1B. Each Subsequent Permit Application for Identical Equipment at Same Site / $300
2A. Permit Application at Same Site for Different Equipment:
Basic PermitWorks Fee / $600
Engineering Fee for permitting assistance over 4 hours for this application / $125/hr
2B. Each Subsequent Permit Application for this Equipment Type at this Site / $300
(Note: Use separate service agreement for permit applications at different sites.)
For your information, permit application processing fees for some boilers, engines and ovens within SCAQMD are shown below. For fee estimates for other air districts or other types of equipment, please call the Air Quality AnswerLine at 1-800-GAS-2000.
SCAQMD Permit Application Processing Fees *Equipment / Size / Schedule / Fee ($)
Boilers / 2 - 5 MMBtu/h / B / 1,370.62
5 - 20 MMBtu/h / C / 2,167.92
20 -50 MMBtu/h / D / 2,992.09
> 50 MMBtu/h / E / 3,440.00
IC Engines / 50 -500 HP / B / 1,370.62
> 500 HP / C / 2,167.92
Bakery Ovens / > 2 MMBtu/h / C / 2,167.92
Other Ovens / > 2 MMBtu/h / B / 1,370.62
Each subsequent permit application for identical equipment at same site / 50% of the permit fee for the first piece of equipment
*Based on SCAQMD Rule 301;fees valid until 6/30/2003.
January, 1999