Statewide Portable Equipment Registration Program

FORM 40 - Notification of Operation in an Emergency Event

(Auto-fill format. Use “Tab” or up/down arrows to enter information. Additional form information is provided on the reverse side.)

PERP forms are available at http://www.arb.ca.gov/portable/portable.htm.

Complete this form if you are operating portable equipment which is normally subject to air permit requirements but is exempt during a declared emergency. Please see reverse side for additional form and program contact information.

Company Information

1. Company Name:
2. Mailing Address:
City: / State: / ZIP:
3. Phone Number: / E-Mail Address:
4. General Nature of Business:
Emergency Event/Project Information
5. Location (Address): / Dates of Operation:
Begin:
Estimated End: / Emergency Event/ Project Type:
Engine/Equipment Information
6. Engine Powers: Generator Compressor Pump Drill Other (Specify):
7. Manufacturer: / 8. Model:
9. Serial Number: / 11. Engine Rated Horsepower (bhp):
11. Primary Fuel:
Diesel Gasoline
Natural Gas Propane / 12. Year of Manufacture:
13. For Certified Engines, Enter the U.S. Environmental Protection Agency ENGINE FAMILY NAME:
READ FAMILY NAME DIRECTLY OFF OF THE ENGINE
I hereby certify that all information provided in this report is true and correct.
14. Printed Name of Owner/Operator:
/ Title:
15. Signature: / Date:


Form 40 Instructions

Note: Use this form only if the engine or equipment unit is operating during an emergency event as defined in section 2452(j) of the Portable Equipment Registration Program regulation. This form may either be mailed in a hardcopy or emailed to Portable Equipment Registration Program (PERP) staff. Submit this notification for each project location AND keep a copy onsite with the equipment. If you have questions do not hesitate to contact PERP staff. Please see below for contact information.

California Air Resources Board

Portable Equipment Registration Program

P.O. Box 2038

Sacramento, CA 95812

Email:

Website: http://www.arb.ca.gov/portable/portable.htm

1.  Company Name - Legal name of entity, business, organization, agency, or private individual that owns or operates the portable equipment.

2.  Mailing Address - Address where the company or owner can be contacted.

3.  Company Information - The email, phone, and fax numbers need to belong to the company, not a third party. Examples of third party members are consultants, distributors, sales representatives, lawyers, etc.

4.  General Nature of Business - Please state the type of business conducted by entity seeking registration. Examples include water well drilling, construction, renter of portable equipment, solid waste facility, etc.

5.  Project Information – Provide the address or other information identifying the location, the dates of operation, and a description and purpose of the project.

6.  Engine Powers - Describe what the engine powers such as a drill rig, pump, compressor, generator, etc.

7.  Engine Manufacturer - For example: Caterpillar, Detroit Diesel, John Deere. Please be sure this is the manufacturer of the engine, not the compressor, generator, etc. which the engine powers.

8.  Engine Model - The model number will likely be either a series of numbers or letters or a combination of numbers and letters. For example: 4045DF150.

9.  Serial Number – Engine Serial Number - A unique, unit specific number, usually on the engine nameplate or stamped into the engine block. For example: PE4045D123456.

10.  Engine Rated Horsepower (bhp) – The maximum brake horsepower rating on the nameplate of the engine.

11.  Primary Fuel - Specify diesel, gasoline, propane, or natural gas.

12.  Year of Manufacture – The year engine was built, not the year of manufacture of the unit the engine powers.

13.  Engine Family Name – If the engine is an EPA or CARB certified engine, provide the 11 or 12 character engine family name. The family name will be on a tag or label with the heading “Important Engine Information” or “Emissions Information.”

14.  Printed Name of Owner/Operator – Name of the owner or operator of the equipment submitting the report.

15.  Signature with Date - Please sign and date.

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