ATTENTION REQUESTOR: To expedite your request for District records, please fill out this form completely, and identify specifically the type of records you are requesting. Please limit your request to one facility or one site address for each request form filed. Additional forms can be used if requesting information for more than one facility or for records not identified on this form. Requests should reasonably describe identifiable records prepared, owned, used, or retained by the District. Public Records Unit staff is available to assist you in identifying those records in the District’s possession. The District is not required by law to create a new record or list from an existing record.

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Requester Information:

 *

Requester Information:

NAME:	DATE:
COMPANY:	MAILING ADDRESS:
CITY:	STATE:
ZIPCODE:	PHONE NUMBER:ext.
E-MAIL ADDRESS*:

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Requested Records:

Requested Records:

Applications (APPLS)	Permits to Operate (P/O)	Notices of Violation (NOV)
Notices to Comply (N/C)	Complaints	Site Inspection Reports (I/R)
Emissions Reports	Test Reports & Protocols	Engineering Evaluations
Air Monitoring Data	Asbestos Notifications/Records	Toxic-Health Risk Assessment (HRA)
Facility Correspondences	Other (Please Describe): If other, type text here.

TIME PERIOD OF DOCUMENTS REQUESTED: 

TIME PERIOD OF DOCUMENTS REQUESTED:

FROM:

TO:

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Requested Facility Information (If Applicable):

Requested Facility Information (If Applicable):

FACILITY NAME:

FACILITY ADDRESS:

CITY

STATE:

ZIP CODE:

FACILITY I.D. NO. (If Known):

APPL. AND/OR PERMIT NO. (IF Known):

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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