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Air Pollution Survey - CITY OF WOODLAND


									                   Community Development Department, 300 First St, Woodland CA 95695 (530) 661-5820 Fax (530) 406-0832

                                            BUILDING INSPECTION DIVISION
                                                     AIR POLLUTION SURVEY

Project #                    Permit #:                                             Date:                    Type of Project
                                                                                                              (check one)
Address:                                       Subdivision:                                 Lot:
                                                                                                            [ ] Residential, 5+units
Project Name:                                                                                               [ ] Commercial/Industrial
Applicant’s Name:                                                                                           [ ] Commercial/Industrial
                                                                                                                New Construction
Mailing Address:                                                                                            [ ] Demolition
                     Street Address                             City               State    Zip

Telephone Number: (          )

If you answer “YES” to Question 1, 2, or 3 under penalty of Federal, State and Air District Regulations you are required to contact the
Yolo-Solano Air Quality Management District (530-757-3650) and obtain approval for your activity.

A Certificate of Occupancy will not be issued if you have not met the requirements of Health and Safety Code Section 25505 and
25531 and Government Code Section 65850.2. Those sections of the Health and Safety Code and Government Code are enforced by
Yolo-Solano Air Quality Management District.

Q1? Does the business use, process or have, machinery of which emits emissions or need a permit from Air Quality Management

            YES              NO

Note: Air Quality Permits are generally required for any process, operation or fabrication which emits gasses, vapors or dust into the
ambient air. The attached sheet lists types of facilities currently under permit from the Yolo-Solano Air Quality Management District.

Q2? Is, or will, your business be located within 1000 feet of a school?

            YES              NO

Q3? Will your activity involve the demolition of a load-bearing wall in any portion of a building?

            YES*             NO                        *If YES fill out asbestos abatement form.

I, the undersigned, certify under penalty of perjury that the above information is true and correct.

Signature of Representative:                                                                Date:
                                            TYPES OF PROCESSES WHICH MAY
                                                REQUIRE AIR QUALITY

Agricultural Products
        Grain/Seed/Nut processing /bulk storage /packaging /shipping

Chemical and Plastics
       Fiberglassing /Plastics products /Agricultural (ammonia)

Dry Cleaning
       Cleaning taking place on the premises

       On site boilers (heat input > 1,000,000 BTU’s/hr and engines

Food Processing
       Canning /Sugar production /use of boilers and large ovens

Mining and Mineral Processing
       Concrete storage /bagging /mixing/ sandblasting /soil mixing /storage/ aggregate processing


Internal Combustion Engines
        Gasoline /Diesel /Natural gas powered engines larger than 50 brake horsepower including emergency generators

Petroleum Products
        Fuel dispensing /bulk storage

Mobile Home/ Woodworking
       Assembly /Sawing /Sanding

Solvent Use-Vehicle /Degreasing /Printing /Woodworking
        Auto body painting /Wood products varnishing & painting /Machine shops with degreasing /Cabinet shops /Print shops

Groundwater and Soil Remediation Projects

For Further Information call the Yolo-Solano Air Quality Management District at (530) 757-3650 or (800) 287-3650.
TO:                  City of Woodland Building Inspection Division
                     300 First Street
                     Woodland, CA 95695

FROM:                Yolo-Solano AQMD (530) 757-3662
                     1947 Galileo Court, Suite 103
                     Davis, CA 95616


Address/Project Name:


Application #:

[ ]       This Application/Proposal is Exempt by this Agency.

[ ]       This Application/Project has been reviewed and needs no further review by this Agency.

[ ]       This Application/Proposal requires more information. Please have Applicant contact me.

[ ]       This Application/Proposal will require approval and a permit from this agency.

[ ]       Building Permit issuance is approved.

[ ]       This Applicant has met all the requirements of this agency as of              .

[ ]       Will need final inspection by this agency prior to Occupancy Certificate.

Name/Title:                                                    Date:



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