HomeMy WebLinkAbout102 Pacific Coast Hwy - CofO (2)i
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SUPPLEMENTAL INFORMATION
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1.
BUSINESS ADDRESS
2.
Person to contact in case of emergency'
Telephone number: t`oY 'y-6
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3.
Does the building in question have electricity?
Yes
❑ No
(a) If No, are you requesting that the electricity be
❑ Yes
turned on?
❑ No
4.
The building is sprinklered?
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5.
Operations will produce dust/wood shavings or similar
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material?
❑ Yes
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`QyNo
6.
Operations will involve the repair or replacement of
❑ Yes
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automobile parts?
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If Yes:
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(a) Describe the components repaired or replaced.
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(b) Does the operation involve the use of an open flame?
❑ Yes
2--No
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7.
The business is drinking, dining or assembly use that will
result in an occupant Load of more than 50 persons.
❑ Yes
No
8.
The following best describes my operation;
Office Only
Retail Sales
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Warehouse
a
Manufacturing / Distribution (describe process and end product)
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Rests Take O ood
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Medical / den ai
Other (descrbbe)
SUPPLEMENTAL INFORMATION
SUPPLEMENTAL
INFORMATION (Continued)
1
Does
the operation involve any of the
following materials?
171 Yes
PNo
If
Yes, indicate gc-antities:
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Material
Quantityl
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1.
Flammable liquids
Class I -A
Class I-B
Class I-C
2.
Combustible liquids
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Class 11
_Class lil-A
3.
Combination flammable liquids
4.
Flammable gases
5.
Liquefied flammable gases
6.
Flammable fibers - loose
7.
Flammable fibers - baled
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B.
Flammable solids
9.
Unstable materials
10.
Corrosive liquids
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11.
Oxidizing material - gases
92.
Oxidizing material, - liquids
13.
Oxidizing material - solids
—
14.
Organic peroxides
15.
Nitromethane (unstable materials)
16.
Ammonium nitrate
17.
Ammonium nitrate compound mixtures
containing more than 60% nitrate
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by weight.
18.
Highly toxic material and
poisonous gas
19.
Smokeless powder
20.
Black sporting powder
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I hereby certify that the above information
is true and correct
to
the best of my knowledge.
Signature
Date
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SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
(Nonresidential Buildings Only)
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Location of Subject Property:_10a S Q�c f.S'-_�Ct �Vw %klykn F'-'L
Property Owner Name:___.___ _ -_-_ __-- Phone
Name of the person preparing this form in print and signature:
Name: -
CI Signature:_ r�n3�pr
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The person preparing this form must be the same person applying for building permits. Please answer the
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following questions regarding your proposed occupancy of the subject building. IF YOU DO NOT KNOW
THE ANSWER TO A QUESTION, MARK IN THE "YES" COLUMN:
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AQMD PERMITTING CHECKLIST
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YES NO
1. Does your facility use any internal combustion engines greater than 50HP?
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2. Does your facility involve mixing, blending, or processing any solvents,
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adhesives, paints or coatings?
3. Does your facility create arty dusts or smoke? _
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4. Does your facility refine any liquids or solids or reclaim any metals?
5. Does your facility plate or coat anything? _
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6. Does your facility have any combustion equipment (i.e, boiler, furnaces,
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broiler, baking ovens, etc.) rating greater than 2,000,000 BTU/HR?
7. Does your facility handle or store solvents or motor fuel? _ x
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8. Do you use or store any acids? k
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9. Do you use any chemical process?
10. Do you use any solvents for clean-up?
11. Are you a dry cleaner, restaurant with a charbroiler, body shop, gasoline
station, printer, br part coater?
12. Is the subject building located within one thousand (1,000) feet of any y
school? PROPERTY LINE TO PROPERTY LINE. GRADES K-12.
If you have marked "NO" in all columns, you do not need an Air Quality permit at this time. If you have marked
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any questions in the"YES" column you must contact the South Coast Air Quality Management District located at:
21865 E. Copley Drive
Diamond Bar, CA 91765-4182
Please call: Plan Check (909) 396-2000