ISR Project Number: / Project Description:
Project Name:
Project APN(s):
B. Current Project Developer Prior to Change
Applicant/Business Name:
Mailing Address:
City: / State: / Zip:
Name of Contact Person: / Title:
E-Mail: / Phone: / Fax:
Billing Address: (if different from Mailing Address)
Street: / City: / State: / Zip:
C. New Project Information
Project description same as above.
Project name change only.
New project name: / New project name & project description.
(Please fill out AIA application)
available at:
http://www.valleyair.org/ISR/ISRFormsAndApplications.htm
D. New Project Developer
Applicant/Business Name:
Mailing Address:
City: / State: / Zip:
Name of Contact Person: / Title:
Is the Applicant a licensed state contractor? No Yes, please provide State License number:
E-Mail: / Phone: / Fax:
Billing Address: (if different from Mailing Address):
City: / State: / Zip:
Central Regional Office: 1990 East Gettysburg Avenue Fresno, California 93726-0244 TEL (559) 230-5800 FAX (559) 230-6064
Page 3 of 2 Form #: ISR001
E. Change of Project Developer CertificationCurrent Project Developer
The current project developer must sign this section. The District will not accept signatures from any party but the current project developer.
I hereby certify that I am the current developer of the project described in Section A of this Change of Project Developer Form and that I have read and understand the requirements identified in this Form. I hereby certify that I relinquish this project, or the specified portion thereof, as described in Section C of this Change of Project Developer Form, to the new project developer, and have notified the new developer of all ISR requirements for this project.
By my signature below, I represent that I have the authority to execute this change of project developer certification of the project and that the information submitted in this Form is, to the best of my knowledge and belief, true, accurate, and complete.
Current Project Developer Name (printed): / Title:
Current Project Developer Signature: / Date (mm/dd/yy):
New Project Developer
The new project developer must sign this section. The District will not accept signatures from any party but the new project developer.
I hereby certify that I am the new project developer of the project, or the specified portion thereof, as described in Section C of this Change of Project Developer Form, and that I have read and understand the requirements identified in this Form. I hereby certify that I have read and understand the District Rule 9510 Indirect Source Review (ISR) requirements for the project referenced above, I agree to comply with all requirements set forth in Rule 9510, including but not limited to payment of all past due and future fees, and that the construction and/or operation of the project will be in accordance with all plans, specifications, reports, Air Impact Assessment (AIA) application submittals and related communications approved by the San Joaquin Valley Air Pollution Control District (District).
By my signature below, I represent that I have the authority to execute this change of project developer certification of the project, and that the information submitted in this Form is, to the best of my knowledge and belief, true, accurate, and complete.
Please check the applicable box:
New Project Developer acquiring the whole project.
New Project Developer acquiring only a portion of the project. Attached are the following required items:
1) AIA application form (available at http://www.valleyair.org/ISR/ISRFormsAndApplications.htm), and
2) AIA application filing fee.
New Project Developer Name (printed): / Title:
New Project Developer Signature: / Date (mm/dd/yy):
Central Regional Office: 1990 East Gettysburg Avenue Fresno, California 93726-0244 TEL (559) 230-5800 FAX (559) 230-6064
Page 3 of 2 Form #: ISR001