Check Before you Burn Exemption Request

Use this form to request an exemption from Section 301 of Sacramento Metropolitain Air Quality Management District Rule 421, Mandatory Episodic Curtailment of Wood and Other Solid Fuel Burning.

All information submitted with this form will remain confidential to the extent permitted under the California Public Records Act (§ 6250).

Applicant Phone Number

Reason for Exemption

My home has a heating system that is broken, unsafe or inadequate

Wood burning is the only source of heat in my home (will be verified with county records)

Financial hardship

Please describe the problem with the heating system

Please upload a recent repair or replacement estimate from a licensed company

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Number of people living in your home including adults and children under 18

Gross Monthly Household Income

Total amounts for all people in the household.

Wages

Rental/Royalty Income

Scholarship/Grant Money

Pensions

Social Security

State Disability Insurance

Disability/Worker’s Compensation

Unemployment

Other (interest income, cash receipts, etc.)

Total Gross Monthly Household Income

If applicable, please provide additional information on your hardship.

Please upload copies of income documentation (paystubs, benefit letters, tax forms, etc.) for everyone living in your home

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Please upload last paid utility bill(s).

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I certify the information contained in this application is accurate to the best of my knowledge under penalty of perjury under the laws of the State of California. I authorize an inspector from Sacramento Metropolitain Air Quality Management District to inspect my residence to verify these statements.

Applicant Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Updated October 2020