 South Coast Air Quality Management District, Form 500-ACC (2009.04) 

South Coast Air Quality Management District 

Form 500-ACC

Title V - Report For Annual Compliance Certification 

Page of 

1. Facility Name (Business Name of Operator That Appears On Permit): 2. Valid AQMD Facility ID (Available On Permit Or Invoice 

Issued By AQMD): 

 

3. This report is based on the applicable rules, permit terms and requirements as specified in Sections A 

through K and Appendices A and B inclusive, and any compliance plans, variances, and alternative 

operating conditions in effect during the permit term of the Title V Facility Permit to Operate issued on: 

(mo/day/year) 

5. This report supersedes a semi-annual monitoring report previously submitted on: 

(mo/day/year) 

Section I - Operator Information 

1. Compliance Status for the Reporting Period: 

a. This facility has been in compliance with all terms and conditions in the Title V permit as referenced in Section I. 

b. This facility has been in compliance with all of the terms in the Title V permit as referenced in Section I, except non-compliance for: 

(Attach additional pages as needed.) 

2. The methods used for determining the compliance status are: 

a. Entirely consistent with the applicable requirements in the permit terms and conditions of the Title V permit. 

b. Partially consistent with the applicable requirements in the permit terms and conditions of the Title V permit, with the exception of: 

Describe in detail how the methods used are different from those listed in the permit and to what extent the devices or operations at the facility are 

impacted. Attach additional pages as necessary. 

Section II - Annual Compliance Certification Report 

Permit Condition Or Rule 

Number(s) Device Number(s) Was Form 500-C2 previously submitted for the non-compliance? (Attach additional sheets as necessary) 

 Yes, on: 

(mo/day/year) 

No, Form 500-C2 is attached to this report 

 Yes, on: 

(mo/day/year) 

No, Form 500-C2 is attached to this report 

 Yes, on: 

(mo/day/year) 

No, Form 500-C2 is attached to this report 

 Yes, on: 

(mo/day/year) 

No, Form 500-C2 is attached to this report 

4. This report 

is due: 

 (mo/day/year) 

and covers the 

period from: 

 (mo/day/year) 

to: 

 

 (mo/day/year) 

 Additional information may be required to comply with Section K Condition 24 of your Title V permit. 

* 

* 
 South Coast Air Quality Management District, Form 500-ACC (2009.04) 

Page 2 of 2 

Mail 1st Copy to: Cher Snyder, Sr. Enforcement Manager 

South Coast AQMD 

P.O. Box 4941 

Diamond Bar, CA 91765 

1. Signature of Responsible Official: 

 

2. Title of Responsible Official: 

 

3. Print Name: 

 

4. Date: 

 

5. Phone #: 

 

6. Fax #: 

 

7. Address of Responsible Official: 

 

Street # City State Zip 

I certify under penalty of law that I am the responsible official for this facility as defined in AQMD Regulation XXX and that based on information and 

belief formed after reasonable inquiry, the statements and information in this document and in all attached application forms and other materials are 

true, accurate, and complete. 

Section III - Responsible Official Signature Statement 

3. Compliance is: 

a. Continuous 

b. Intermittent 

 If Intermittent, describe intermittent compliance in detail. Attach additional pages as necessary. 

4. Are there any other facts or circumstances that have been required to determine the compliance status of the facility (e.g., compliance plans, terms 

of a variance, or order of abatement)? 

a. No 

b. Yes 

 If Yes, Please Explain 

Mail 2nd Copy to: USEPA, Region IX, Air-3 

Director of Air Division 

75 Hawthorne Street 

San Francisco, CA 94105