Form 222-Ag Agricultural Engine Registration
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1
2South Coast Air Quality Management District
APPLICATION FOR RULE 222
P. O. Box 4944
FORM 222-Ag
Diamond Bar, CA 91765
(909) 396-2000
Agricultural Engine Registration
Section I – Administrative Information
LEGAL NAME OF OPERATOR/OWNER
BUSINESS MAILING ADDRESS
STREET
CITY
STATE
ZIP CODE
EQUIPMENT ADDRESS/LOCATION
STREET
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
Section II – Technical Information
FOR
This application form is for the registration of existing and new stationary (emergency and non-emergency)
SCAQMD
and portable compression ignition (CI) engines rated greater than 50 bhp that are used in Agricultural
USE
Operations. CI engines used to power agricultural wind machines or CI engines that provide motive power
(i.e. motor vehicles, tractors) are not subject to registration. Use one Form only for each engine. [Pursuant
to CARB ATCM, CCR, Title 17, Sections 93115.3(a) & 93115.8(c)]
FILING FEE (FOR EACH ENGINE): $163.71 (EFFECTIVE 7/1/08 - 6/30/09)
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APPLICATION TYPE: (check all that apply)
New Engine*
Existing In-Use Engine
Modification
Change of Owner
Date initially installed in the District: __________________________ *New Engine (installed on/after 1/1/2005)
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ENGINE USE:
Water Well Pump
Booster Pump
Electrical Power
Irrigation Pump
_
Other (describe): __________________________________________________________________________
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ENGINE CLASSIFICATION:
Stationary
Seasonal
Portable
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ENGINE DATA:
Pre-2005
Post-2005
Purchase date ________________
Installation Date: ________________ Manufacture Date: _____________ or Approximate Engine Age: _______
Fac I.D.
Make: ____________________________ Model: ________________ Serial No: _________________________
________
Maximum Rated Brake Horsepower: BHP _________ EPA Engine Tier: _____ (options: Tier 0, 1, 2, 3 or 4)
Appl No.
Fuel Used:
Diesel
Bio-Diesel (incl. % Diesel) _____
Other (describe): _____________
_______
Estimated Average Fuel Use: ___________ gallons/yr
Average Operating Hours: ________ hrs/yr
EPA Family Name (if known): _________________ CARB Executive Order (if known): ____________________
I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED HEREIN AND INFORMATION SUBMITTED WITH THIS APPLICATION IS TRUE AND CORRECT.
SIGNATURE OF RESPONSIBLE OFFICIAL OF FIRM:
DATE SIGNED:
/
/
TITLE OF RESPONSIBLE OFFICIAL OF FIRM:
TYPE OR PRINT NAME OF RESPONSIBLE OFFICIAL OF FIRM:
RESPONSIBLE OFFICIAL’S TELEPHONE NUMBER
(
)
-
AQMD
CHECK/MONEY ORDER
AMOUNT
VALIDATION
#
USE ONLY
Form 222-Ag (3/2009)
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