 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 determ ining 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 except ion of:

Describe in detail how the methods used are different from those listed in the permit and to what extent the devices or operati ons 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 1 st 

### 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 a nd 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 re quired 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 2 nd



### Copy to: USEPA, Region IX, Air-3

Director of Air Division

75 Hawthorne Street
San Francisco, CA 94105