South Coast Air Quality Management District 21865 Copley Drive Diamond Bar, CA 91765
909.396.2000 

# Rule 1415 Registration Form

FACILITY INFORMATION AQMD ID # OR New Busi ness

FACILITY
NAME

LOCATION
ADDRESS

CITY STATE 

## CA ZIP
CODE CONTACT
PHONE

CONTACT
PERSON TITLE OF CONTACT
PERSON

TYPE OF
BUSINESS BUSINESS TYPE CODE (SEE INSTRUCTIONS)

ANNUAL
ENERGY USE 2008 kWh/year 2009 kWh/year FACILITY
AREA square feet

FOR THIS PROJECT, HAS A CALIFORNIA ENVI RONMENTAL QUALITY ACT (CEQA) DOCUMENT

BEEN REQUIRED BY ANOTHER GOVERNMENT AG ENCY? YES NO

IF YES, ENTER NAME OF AGENCY: DO YOU CLAIM CONFIDENTIALITY OF DATA?

YES NO



## EQUIPMENT INFORMATION

F OR EACH REFRIGERATION SYSTEM AT THE ABOVE FACILITY LOCATION THAT HOLDS >50 LBS . O F CFC (C HLOROFLUOROCARBON ) OR HCFC (H YDROCHLOROFLUOROCARBON ) REFRIGERANT

. PLEASE PROVIDE THE FOLLOWING INFORMATION : ANNUAL ADDITIONAL REFRIGERANT (lbs.)

UNIT
>50
lbs. F/R/A
TYPE MANUFACTURE R MODEL
YEAR SERIAL NUMBER REFRIGERANT
TYPE STORAGE CAPACITY (lbs. of refrigerant) DATE OF LAST AUDIT/

MAINTENANCE USAGE YEAR (2008) USAGE YEAR (2009)



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So that your account can be credit ed properly, please mail the completed form(s), along with a check for $114.66 to cover the Rule 1415 Registration Plan fee for your facility, to the following address:

Area Sources South Coast Air Quality Management District 21865 Copley Drive Diamond Bar, CA 91765

If there are more than 8 units please attach an additional form.



## COMPANY INFORMATION

COMPANY
NAME CONTACT
PERSON

MAILING
ADDRESS CITY STATE ZIP
CODE

CONTACT
PHONE E-MAIL FAX

SIGNATURE DATE

AQMD USE APPLICATION NO. DATE CHECK NO. AMOUNT
$ ASSIGNMENT

UNIT

NUMBER
OF
FACILITIES EQUIP. CAT. NO.

____ ____ ____ ____ ____ ____ ENGINEER

A R DATE INITIAL
Registration Form 1415; Rev 07/10

# Rule 1415 REGISTRATION FORM
INSTRUCTIONS

FACILITY INFORMATION

FACILITY NAME For identification purposes, please enter the name of the facility which owns/operates the subject refrigeration equipment.

AQMD ID# OR New Business. This information is used for identification purposes. Please enter the AQMD company identification number. If you are a new business check that box and we will create an AQMD ID for your business.

LOCATION ADDRESS Please identify the address where the equipment or facility
is located. If no street addr ess is available, please provide a location description and zip code.
CONTACT PERSON, TITLE, AND PHONE NUMBER Please identify the name, title and phone number of the person who would be contacte d at the equipment location.

TYPE OF BUSINESS This information is used by the AQMD for planning and statistical purposes. Please state the type of business you conduct in this facility (e.g. hotel, retail store, etc.).

BUSINESS TYPE CODE This information is used by the AQMD for planning and statistical purposes. Referring to the provided list of business codes, please enter the code which best describes your business activity at this facility.

FACILITY AREA AND ANNUAL ENERGY USE Indicate the approximate square footage of the facility’s indoor area, and the total ener gy used over the course of the calendar year in kilowatt-hours (kWh/year). The energy use can be taken from utility bills or other
available documentation.

CALIFORNIA ENVIRONMENTAL QUALITY ACT A California Environmental Quality Act (CEQA) document (e.g., environmental impact report, negative declaration) is required for any project which results in significant
effect on the environment. If such a document has been required by another governme ntal agency, please enter the name of that agency. A copy of this document is also required before the registration can be deemed complete. Therefore, please submit a copy of the approved document. In most cases the answer to this question is

“no.”

CONFIDENTIALITY District records are subject to the California Public Records Act. To claim confidentiality of information submitted with this registration, check "yes." Please be sure that all
submitted information that you wish to be kept confidential is clearly marked as such. Please also state the reason(s) for claiming confidentiality. Examples of acceptable reasons are trade secrets and production data.
Please note that state law prevents emissions data and permit documents from being kept secret. + 

### EQUIPMENT INFORMATION

F/R/A TYPE Please indicate whether the unit is a freezer (F), a refrigerator (R), or an air conditioner (A).

MANUFACTURER Please identify the manufacturer of the unit.

MODEL YEAR Please identify the model year of the unit.

SERIAL NUMBER Please identify the serial number of the unit.

REFRIGERATION TYPEPlease indicate the type of chlorofluorocarbon (CFC) or hydrochlorofluorocarbon (HCFC) used as refrigerant in each system.

STORAGE CAPACITY Enter the total refrigerant storage capacity of each unit.

DATE OF LAST AUDIT/MAINTENANCE In accordance with Rule 1415 (d)(2), an annual audit/ maintenance inspection is required for all refrigeration systems subject to this rule. Indicate the last date the appropriate audit/inspection was conducted.

ANNUAL ADDITIONAL REFRIGERATION Usage Year 2008 Indicate the total quantity of refrigerant (in pounds) that was added to each system during the 2008 calendar year

. Usage Year 2009 Indicate the total quantity of refri gerant (in pounds) that to date has been added to each system for the 2009 calendar year.


### COMPANY INFORMATION

COMPANY NAME For identification purposes, please enter the name of the entity responsible for the submittal of the registration, typically the owner/operator of the equipment. The information in this section of the registration form will be used for all future correspondence, including information about subsequent registrations. In the event that the registration form is prepared and submitted by a party other than the equipment ow ner/operator, it is important that the AQMD be notified of any changes to this information.

CONTACT PERSON, MAILING A DDRESS, PHONE, E-MAIL,
FAX Please identify the person’s name that is responsible for the completion and submittal of the Rule 1415 Registration Form, include the appropriate mailing address information, telephone number, E-mail and fax number.

QUESTIONS? If you have questions regarding this registration form or Rule 1415, please contact Heather Farr at (909) 396-3672 or Rizaldy Calungcagin at (909) 396-2315. They may be reached by E-mail

at hfarr@aqmd.gov or rcalungcagin@aqmd.gov

.

DID YOU REMEMBER? 1. To provide all requested information (business type code, last audit/maintena nce and refrigerant added) 2. To sign and date the registration form? 

## 3. To include the required filing fee with your hardcopy registration submittal? 

## 4. To e-mail the registration form to R1415Reg@aqmd.gov



## Rev. 07/10