HomeMy WebLinkAbout15063 GOLDEN WEST - CofO (7),
t�
M
x'
,
SUPPLEMENTAL INFORMATION
4
1.
BUSINESS ADDRESS
Tn LU
r
21
l 5t
2.
Person to contact i n case of emergency.
/��"''✓En/ %�'�G2 gjq
Telephone number:
e
`
3.
f
Does the building in question have electricity?
D No
(a) If No, are you requesting that the electricity be
❑ Yes
D No
d
turned, on?
Yes
4.
The building is sprinklered?'
❑ No
5.
Operations will produce dust /wood shavings or similar
❑ Yes
material?
®-1Qo
6.
Operations will involve the repair or replacement' of
❑ Yes
040
`
automobile parts?'
11 Yes:
(a) Describe the components repaired or replaced.
(b) Does the operation involve the use of an open flame?
❑Yes
C�
# 7.
The business is drinking, dining or assembly use that will
❑ Yes
result in an occupant load of more than 50 persons.
C�--fro
8.
The following best describes my operation;
i
Office Only
Retail Sales
Warehouse
Manufacturing /Distribution (describe process and end product)
Restaurant / Take Out Food
Medical / Dental - �•
Other (describe)
1
SUPPLEMENTAL INFORMATION
,
J. 1
,j
5
k
�,
s
SUPPLEMENTAL INFORMATION
(Continued)
Does
the operation involve any of the following materials? El Yes
f17-�Pd'o"
lies:
Yes, indicateu quantities:
f e
uanterial it
M aY
a
1. Flammable
liquids
Class I -A
Class I-B
Class I-C
2.
Combustible liquids
Class 11
Class III -A
i
t t
3.
Combination flammable liquids
' 4.
Flammable gases
5.
Liquefied flammable gases
, ,
6.
Flammable : fibers - loose
7.
Flammable Tibers - baled
�.
Flammable sn-!Rds ^.
9.
Unstable materials
_
10.
Corrosive ligwds
11.
Oxidizing material - gases
s
12.
Oxidizing material - liquids
'
13.
Oxidizing' material - solids
f
14.
Organic peroxides
*5.
Nitromethane (unstable materials)
.,
{
I 16.
Ammonium nitrate
—
17.
Ammonium nitrate compound ^iixturss
u
containing more than 60% nitrate:
' e
by weight-----
1€3.
Highly, toxic material and
poionous gas
-\
�l
19.
Smokeless powder
20.
Black spurting powder
—
I hereby certify that the above information is
true and coa : eca `to
'
the best, 'of my knowledge_
9
Signature
Date
Ir
.«;-•.rc.-"'g"^r-.^—..�-.m----.
y
x..-.+,x,-,:�e��.,�,..-qr..r.-.�=._ 5-;s'�'_^",.,,^»^.•,'--'u�"fi,,,.,,.,,,-'"^ .-*".."'
,.�,-rt-+^+ ^".;.,"'"'r"»
,,."--.�,�_
..,r..rn>+...:,,*>..�.—.a.�.,z.
„
t
5
p
�t C
i
South Coast
AIR QUALITY MANAGEMENT DISTRICT
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
AIR QUALITY PERMIT CHECKLIST
for nonresidential buildings only
Company Name: :�,✓
Location of Property: __ / Sty G r''� �j� ��Jj
,,
City:
Zip Code:¢ 7
Contact Person;
Telephone Number: 7iy 90i Di�� � Fax Number:
i;
Type of IndustryBusiness: h yfG - ,7' _s,r�,�/ pG
,.
To apply for a nonresidential building permit, you must complete this checklist. If have any t
questions about completing this checklist, pleasecall (800) 388-2121.
1. Will the facility have a charbroile?
,
rYES
' 2. Will any internal combustion engine with
g greater than 50 horsepower
rN'Oy
operate at the facility (excluding motor vehicles)?-
3. Will operations at the facility involve mixing, blending, or processing of
solvents, adhesives, paints or coatings?
4. Will dust or smoke be generated at the facility?
5 Will refining of any liquids' or solids b,- done at the facility?
6• Will any plating or coating of materials be done
(
at the facili •
7• Will any combustion equipment rated greater than 2,000,000 BTULhr be
operated at the facility?
S. Will any acids, solvents, or motor fuel be used or stored at the facility?
9• Will any organic liquids or gases be
reacted or produced?
10. Will any ovens be used to ) dry or cure products at the facility?
11. Will
any CK (Freon) recycling machines operate at the facility?
Applicant: %�JOAIC < Q Zel Si _ gnature:
_.
(Print name clearly)
If you have marked "NO" in all the boxes, an air quality permit is not needed at this time, and this checklist is your written release.'
t' If you marked "YES" in any of the boxes, you must contact the South Coast Air Quality,
Management District (AQM13). Please read the requirements the back
}
on of the checklist.
1
(800) 388-2121
,tL
e
r
r
'i
�
G>
J — I