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Form 222-B Application For Rule 222 222-B - California
| Form 222-B Application For Rule 222 Form. This is a California form and can be used in Compliance South Coast Air Management District Statewide . |
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South Coast Air Quality Management District P. O. Box 4944 Diamond Bar, CA 91765 (909) 396-2000 APPLICATION FOR RULE 222 FORM 222-B BOILERS/WATER HEATERS AND PROCESS HEATERS (1 2 Million BTU/Hr Heat Input) Section I Administrative Information LEGAL NAME OF OPERATOR/OWNER BUSINESS MAILING ADDRESS STREET CITY STATE ZIP CODE EQUIPMENT LOCATION ADDRESS STREET CITY STATE ZIP CODE E-MAIL ADDRESS Section II Technical Information BOILERS/WATER HEATERS & PROCESS HEATERS EQUIPMENT INFORMATION (EQUIPMENT WITH A RATING HEAT INPUT FROM 1,000,000 BTU PER HOUR UP TO AND INCLUDING 2,000,000 BTU PER HOUR) FOR SCAQMD USE CHECK ONLY ONE BOILER/HEATER (Certified by SCAQMD) (Note 1) RETROFITTED BOILER / HEATER (Note 2) BOILER / HEATER (Gas usage < 9000 therms/calendar year) (Note 3) BOILER / HEATER (Note 4) MFR. _____________________ MODEL NO. _________________ SERIAL NO.__________________ EQUIPMENT RATING (BTU/HR): __________________________ NOTE NOTE NOTE NOTE 1: 2: 3: 4: IF MANUFACTURED ON OR AFTER 1/1/2000, IT MUST BE CERTIFIED PER RULE 1146.2 RETROFITTED (LOW NOX BURNER) TO COMPLY WITH RULE 1146.2 EXEMPT FROM RULE 1146.2 IF GAS USAGE IS LESS THAN 9000 THERMS PER CALENDAR YEAR COMPLIANCE WITH RULE 1146.2 MAY BE REQUIRED FILING FEE: $173.56 PER EQUIPMENT (EFFECTIVE 7/1/12 6/30/13) NOTE: SEPARATE FORM FOR EACH BOILER/WATER HEATER/PROCESS HEATER REQUIRED ____________ FACILITY I.D. # ____________ APPLICATION NO. SIGNATURE OF RESPONSIBLE OFFICIAL OF FIRM: I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED HEREIN AND INFORMATION SUBMITTED WITH THIS APPLICATION IS TRUE AND CORRECT. DATE SIGNED: / TYPE OR PRINT NAME OF RESPONSIBLE OFFICIAL OF FIRM: TITLE OF RESPONSIBLE OFFICIAL OF FIRM: / RESPONSIBLE OFFICIAL'S TELEPHONE NUMBER ( ) - AQMD USE ONLY CHECK/MONEY ORDER # AMOUNT VALIDATION FORM 222-B revised 7/2012 American LegalNet, Inc. www.FormsWorkFlow.com
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