Form 459xmpt - Certification Of Exemption From An Air Quality Permit To Operate - Sacramento Metropolitan Air Quality Management District
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1SACRAMENTO METROPOLITAN AIR QUALITY MANAGEMENT DISTRICT
Th
777 12
Street Third Floor, Sacramento CA 95814 Phone: (916) 874-4800 / Fax: (916) 874-4899
CERTIFICATION OF EXEMPTION FROM AN AIR QUALITY PERMIT TO OPERATE
Company____________________________________________________________Phone____________________________
Type of
Business__________________________________________________________________________________________
Facility
Location______________________________________________________________________________________________
Mailing
Address_______________________________________________________________________________________________
City_______________________________________________________________State______________Zip______________
Exemption from permitting requirements as specified in District Rule 201, General Permitting Requirements, is determined by
the maximum actual usage of coating and solvent materials. Please record in the table below the MAXIMUM ACTUAL daily
usage of coatings and solvents (all types) for any one day you work. Be advised that if the usage of coatings and solvents at
your facility exceeds 1 gallon in any single day after claiming a permit exemption, you will be in violation of District Rule 201 and
may be subject to penalties. Exemption status does not provide relief from the specific requirements (VOC standards,
.
work practices, recordkeeping) found in other District rules to which your facility may be subject
Maximum Actual
Material
Daily Usage
Is total greater than 1 gal/day?
Coatings
______ gal/day
YES:
NO:
Solvents/Strippers
______ gal/day
OBTAIN PERMIT TO
EXEMPT FROM OBTAINING
OPERATE
PERMIT TO OPERATE*
TOTAL USAGE
______ gal/day
* If any coatings used contain hexavalent chrome, you are not exempt from obtaining a Permit to Operate and should notify the
District.
If your answer in the table above is “YES”, complete an Authority to Construct/Permit to Operate application package and
submit it with the appropriate fees to the District. If your answer in the table above is “NO”, complete the remainder of this form
and submit it to the District.
The District may verify the information you are providing against manufacturer and/or distributor sales records. This information
is subject to provisions of the California Health and Safety Code Sections 42303.5 and 42402(a):
42303.5 “No person shall knowingly make any false statement in any application for a permit, or in any information, analyses, plans, or
specifications submitted in conjunction with the application or at the request of the air pollution control officer.” 42402(a) “, any person who
violates…, any rule, regulation, permit, or order of a district, ... , is strictly liable for a civil penalty of not more than one thousand dollars
($1,000)."
I, the undersigned, hereby certify under penalty of perjury that the above information is true and correct to the best of my
knowledge.
Print name of
owner/responsible
officer__________________________________________Title________________________________
Signature of
owner/responsible
officer__________________________________________Date________________________________
459XMPT
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